The Credentialing Specialist is responsible for credentialing and recredentialing Matrix Medical Network (Matrix) providers as well as ensuring enrollment with Medicaid, Medicare and participating client health plans. Credentialing functions include, but are not limited to, processing Matrix Credentialing Applications, performing primary source verifications and updating and maintaining the Matrix credentialing database in accordance with internal policies and procedures, client health plan contracts, NCQA guidelines as well as applicable state and federal requirements.
Perform the initial credentialing and recredentialing functions for employed and contracted Matrix providers, which may include collaborating physicians and Locum Tenens.
Review provider applications for completeness and accuracy.
Ensure appropriate follow-up within established timeframes, monitor and report on the credentialing progress of each provider.
Maintain timely and accurate data entry and periodically revise provider data in the Matrix credentialing database.
Accurately maintain provider files for Matrix providers.
Ensure timely and accurate credentialing and recredentialing application submissions for each provider as it relates to each client health plan; monitor and report progress of each practitioner.
Enroll providers with Medicaid and Medicare and all applicable client health plans; monitor and report on progress of each provider.
Ensure all providers who require collaboration agreements are appropriately assigned to a collaborating physician and the agreement is executed by both parties; monitor and report progress of each provider.
Ensure employed providers are enrolled under the Matrix professional liability insurance plan; monitor and report progress on each practitioner.
Respond to all provider, client health plan and internal inquiries in a timely manner within one (1) business day.
Conduct sanctions and compliance monitoring and alert credentialing leadership of any undisclosed negative findings immediately.
Assist traveling providers with obtaining new state licenses in areas identified by the clinical management team; monitor and report progress of each provider.
Adhere to Matrix policies and procedures including timely delivery of completed work and use of resources.
Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll providers and ultimately bill and obtain reimbursement for services rendered; discover and convey problems to credentialing leadership so that the optimal course of action is taken by making sound decisions in accordance with department and corporate guidelines.
Utilize extensive internet and telephone communication to obtain critical pertinent information.
Keep credentialing leadership informed of potential credentialing or enrollment issues.
Ensure strict confidentiality at all times.
Other duties as assigned.
Associates or Bachelors in Business, Finance, Health Care or related field or high school diploma and relevant combination of education and experience.
Required Skills and Abilities:
Experience with medical and professional credentialing processes, policies and procedures, including delegated credentialing requirements and Medicaid and Medicare enrollment.
Up to three years credentialing experience in a health care setting to include up to two years of provider enrollment, credentialing or network services experience.
Demonstrated ability to work independently.
Ability to manage multiple projects efficiently and accurately.
Strong analytical skills needed to assess compliance, record, analyze and interpret data into meaningful formats.
Strong written and verbal communication skills,
Demonstrated ability and commitment to excellent customer service to maintain and ensure effective working relationships with internal and external clients.
Ability to adapt to change and meet deadlines.
Excellent attention to detail and high degree of accuracy.
Requires exceptional critical thinking skills, sounds judgment and the ability to communicate in an articulate and sensitive manner with providers, administrators, legal counsel and client credentialing personnel.
Experience with MD-Staff or similar provider credentialing, data collection and record management system.
Experience with NCQA, URAC and/or The Joint Commission guidelines and standards related to credentialing.
Experience with MS Office.
Internal Number: 2019- 6506
About Matrix Medical Network
Matrix Medical Network is headquartered in Scottsdale, Arizona, with a national clinical organization. Matrix provides high-touch, in-home care to help health plans balance cost and revenue, grow membership and improve quality of care.