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Conducts primary source verification for prospective providers and re-credentialing of active providers utilizing NCQA and other federal and state regulatory requirements. Resolves complex provider issues relating to credentialing, enrollment, privileging, billing and payers.
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Maintains knowledge of current payor, agency, and third-party requirements for credentialing providers, including, but not limited to, NCQA, URAC, and CMS standards. Reviews credentialing and recredentialing files to ensure that they meet NCQA, URAC, and CMS standards, and payor and company requirements.
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RESPONSIBILITES/DUTIES/EXPECTATIONS : Maintain a thorough knowledge and meet important industry standards set forth by organizations such as NCQA, CMS, ODI, QHP, CAQH, etc. Supports the day-to-day operations (networks, credentialing and contracting) by making appropriate recommendations to supervisor for changes within the Department, including process improvement and problem solving.
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We are hiring a Provider Credentialing Specialist. The Provider Credentialing Specialist is responsible for overseeing and coordinating DMC's onboarding and credentialing process for new providers and ongoing revalidation.
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Previous experience in a network development, provider recruitment or provider contracting. Coordinates Public Policy Research Center (PPRC) activities to assure maintenance of current credentialing status, and evaluation and appropriate actions of quality of care issues and complaints against providers.
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Ability to conduct efficient license verification, and credentialing compliance with NCQA protocol. Demonstrated experience in core functions of physician practice operations, including provider relations, patient flow, revenue cycle, quality, service excellence, purchasing and inventory, and teamwork, and accountability.
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Extensive knowledge of the regional health care provider community, current state and federal legislation and credentialing and contracting protocol, including primary source verification and NCQA (National Committee on Quality Assurance) and URAC requirements.
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Certified Provider Credentialing Specialist (CPCS) preferred. Monitors the initial, reappointment, and expireables process for practitioners, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, Federal/State), bylaws, policies/procedures, and delegated agreements.
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The Provider Resource Coordinator conducts credentialing verification activities for the centralized verification office (CVO) on behalf of the Aspirus system and private practice customers.
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Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) Working knowledge of the health care and credentialing industry, regulatory agencies, and other national standards (TJC, NCQA, AAAHC.
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The Manager, Credentialing & Provider Enrollment oversees daily operations for the Tower Health System, including Tower Health facilities, medical groups, ancillary. Must Have Experience with managed care for payor enrollment and credentialing, NCQA.
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Provider enrollment with contracted commercial and government health plans; primary source credentials verification for delegated credentialing contracts. Management of provider termination for delegated credentialing and managed care dis-enrollment.
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Set up and maintains provider information in online credentialing databases and system. Prepare provider credentialing and re-credentialing files for approval process for facility privileging requests.
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Knowledge of credentialing processes, terminology and NCQA standards. Do you have experience in payor enrollment, provider credentialing or another related healthcare field.
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LICENSES AND CERTIFICATIONS: Certified Provider Credentialing Specialist CPCS or CPMSM certification through NAMSS Preferred QUALIFICATIONS: National Association Medical Staff Services (NAMSS) membership preferred.
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