Credentialing and Provider Enrollment Specialist at Silicon Valley Medical Development – Los Gatos, California

Silicon Valley Medical Development is currently seeking a Skilled Part-Time Credentialing and Provider Enrollment Specialist to join our growing healthcare team!

Location: Los Gatos, CA

Pay: $25.55-$34.06/ hour

Schedule: Monday-Friday 9am-1pm

Silicon Valley Medical Development, (SVMD) LLC is a growing provider organization with community-based ambulatory care clinics and medical practices in Santa Clara County.

SVMD seeks to coordinate care that best fit the needs of the communities we serve, with like-minded people who want to simplify the healthcare experience. With a commitment to teamwork and quality, together we can offer exceptional care to our patients.

The Credentialing and Provider Enrollment Specialist is responsible for taking a new provider application in accordance with applicable organizational policies and procedures from receipt to inclusion in payer directories and making ongoing updates. He/she performs all assigned activities associated with initial appointments and re-appointments, ensuring compliance with the appropriate accrediting and regulatory agencies including verification, peer recommendations, and follow-up on concerns that may delay completion of the credentialing or re-credentialing processes. This involves accurate and timely entry of provider data, including provider applications and contract information, status changes, payee changes. It also includes verification of all the credentialing criteria for practitioners' initial credentialing, re- credentialing, and following up with practitioners and payers as needed to obtain or supply information for the credentialing process and continued network participation with the payers.

Responsible for the accuracy and integrity of the credentialing database system and related applications. He/she will track and update databases to reflect current compliance with credentialing and privileging elements for enrolling individual providers and provider groups with payers.

Essential Functions:

Credentialing:

• Implements, coordinates and maintains credentialing and re-credentialing provider files, prepares credentialed files for completion and presentation, and ensures file completion
• Performs timely follows-ups with providers, identifies, and responds to issues that require additional investigation and evaluation, validates discrepancies with provider and reports to leadership
• Preforms on-going monitoring of credentialing sanctions
• Maintains provider confidentiality at all times and maintains effective communication and professional interaction with providers.
• In collaboration with the Credentialing Committee Chair, assists with meeting agenda, and meeting minutes
• Assists with managed care delegated credentialing audits
• Provides support with payer inquiries in which SVMD is delegated for credentialing on various matters pertaining to credentialing

Provider Enrollment

• Works closely with management to ensure seamless coordination and timely enrollment of new providers coming into the organization.
• Applies in-depth working knowledge of the various payer applications associated and the workflow process.
• Accurately prepares all required paperwork for newly affiliated and existing healthcare providers for payer enrollment/re-enrollment.
• Maintains, updates and attests CAQH provider profiles for employed providers on an ongoing basis.
• Ability to use government and payer websites for provider enrollment
• Manages monthly roster and data requirement of the payers
• Maintains and updates employed provider enrollment insurance tracker
• Works with payers on enrolled provider issues and seeks resolution
• Responsible for communicating any potential issues with providers not completing required paperwork.
• Assists in synchronization of data among health system
• Manages provider directory verification and participation process with payers and external websites.
• Validates provider enrollment on payer websites for accuracy
• Maintains and updates provider directory both internally and externally
• Responsible for retaining a professional working relationship with all payers and providers.
• Performs work in accordance with established schedules, policies and procedures
• Contributes to the overall provider experience and satisfaction
• Participates in performance improvement activities
• Adheres to HR, safety, HIPAA and compliance policies, and attendance requirements
• Performs other duties as assigned

Minimum Requirements:

• High School Diploma or GED
• 2 years of college or equivalent work experience in a managed care environment (i.e., IPA or Health Plan)
• Knowledge of credentialing applications/programs
• Proficient in Microsoft Office product suite (including Outlook, Excel, Word)
• Ability to work within established guidelines and protocols
• Ability to utilize web-based resources for information retrieval purposes
• Ability to work in collaboration with all departments
• Ability to prioritize multiple projects as well as perform other duties as assigned for the department
• Knowledge of NCQA Guidelines and JCAHO to maintain certifications
• Knowledge of ICE regulations for healthcare providers
• Strong working knowledge of applicable guidelines and regulations
• Ability to accurately type a minimum of 40 WPM
• Strong verbal and written communications, and active listening skills
• Solid patient/guest relations skills with the ability to communicate in a professional, courteous and efficient manner
• Ability to perform basic math
• Excellent attention to detail
• Ability to effectively organize and prioritize task in order to complete assignments within the time allotted to maintain standard workflow
• Ability to work effectively as a team member who is flexible, cooperative and willing to assist others