This individual will provide formal detailed documentation of our clinicians' professional histories and thoroughly track the credentialing process to ensure follow-through from start to finish.
Primary Duties and Responsibilities:
- Create and maintain Gather Health's credentialing and recredentialing policies and procedures, and compliance with state, federal, accreditation and insurance payer credentialing requirements.
- Collaborate with leadership on policy development and standardization of criteria / processes across the organization.
- Create and maintain up-to-date credentialing files and database. Maintain a detailed log of all pending and completed work.
- Complete enrollment/credentialing and re-credentialing applications and manage of all various credentialing work streams (e.g. onboarding, credentialing, hospital privileging, Medicare/Medicaid enrollments, health plan enrollments, etc.) for clinicians of Gather Health
- Manage Gather Health’s external credential databases, including CAQH, PECOS, NPPES, Massachusetts Health Professions Licensing Portal, and other regulatory agencies, to ensure data is updated and ready for quick retrieval and use by interested parties.
- Communicate the results and status of the applications to providers, payers, managers, and co-workers. Escalate concerns or missed deadlines to management for further review.
- Maintain provider enrollment within EHR and support Revenue Cycle Management team on any research and resolutions of claim issues related to clinician enrollment.
- Conducts periodic audits of credentialing files and clinician statuses for quality assurance.
- Develops and provides regular reports and presentations concerning the operation and progress of the credentialing functions, including activity related to approvals, denials and / or appeals.
- Minimum five (5) years of Credentialing experience required.
- Certified Provider Medical Services Management (CPMSM) / Certified Provider Credentialing Specialist (CPCS) Certification preferred
- Strong understanding and use of web-based credentialing applications.
- An analytical mind and inclination for problem-solving
- Professional communication skills with both staff, executives, and external customers.
- Attention to detail and strong organizational skills.
- Sense of urgency.
- Flexible and positive attitude.
- High level of integrity.
- Ability to work independently with limited supervision.
- Multi-tasking and ability to set priorities
Gather Health is an Equal Opportunity Employer. All employment decisions are made without regard to age, race, creed, color, religion, sex, national origin, ancestry, disability status, veteran status, sexual orientation, gender identity or expression, genetic information, marital status, citizenship status, or any other basis as protected by federal, state, or local law.
