BHC Credentialing Specialist

GENERAL SUMMARY:

Responsible for facilitating the initial and renewal credentialing process of Bryan Health Connect (BHC) members. Responsible for facilitating the payer enrollment/credentialing processes for Physician Hospital Organization (PHO) members and maintaining provider rosters for all managed care, commercial insurance and Direct-to-Employer (DTE) contracts. Serves as the central liaison for BHC members specific to payer relation issues and assists with problem resolution while maintaining positive relationships with BHC members and payers.

PRINCIPAL JOB FUNCTIONS:

1. *Commits to the mission, vision and beliefs of Bryan Health and consistently demonstrates our core values.

2. *Facilitates the application, verification, enrollment and practice notification credentialing process and accompanying documentation.

3. *Acts as the central liaison with the Bryan Health Benefits department and all other DTE third party administrators/payers to maintain up to date provider rosters.

4. *Manages initial and renewal membership applications and credentialing for BHC member facilities, ancillary, allied health and physician member types.

5. Works directly with any third-party network payer credentialing agents that BHC may contract for primary source verification or other subcontracted payer credentialing services (i.e. delegated payer credentialing).

6. Manages credentialing committee audits and audits of any network payer credentialing agents as per BHC payer credentialing policies and procedures.

7. *Maintains payer credentialing records per BHC payer credentialing policies and procedures and other associated regulatory requirements.

8. Oversees the BHC Credentialing Committee including scheduling, meeting packets, meeting minutes and recommendations to the Bryan Health Connect PHO Board. Processes related physician reimbursement vouchers.

9. Responsible for timely and accurate maintenance member database and enrollment rosters for all BHC managed care agreements.

10. Works collaboratively with Bryan Health CVO team and other credentialing peers at their respective entities.

11. Maintains professional growth and development through seminars, workshops, and professional affiliations to keep abreast of latest trends in field of expertise.

12. Participates in meetings, committees and department projects as assigned.

13. Performs other related projects and duties as assigned.

(Essential Job functions are marked with an asterisk "*". Refer to the Job Description Guide for the definition of essential and non-essential job functions.) Attach Addendum for positions with slightly different roles or work-specific differences as needed.

REQUIRED KNOWLEDGE, SKILLS AND ABILITIES:

1. Knowledge of all laws and regulations related to payer credentialing.

2. Knowledge of managed care and commercial healthcare insurance contract renewal procedures.

3. Knowledge of primary source verification processes, resources and database management programs such as CAQH and MDStaff.

4. Knowledge of HIPAA compliance procedures.

5. Knowledge of computer hardware equipment and software applications relevant to work functions.

6. Skill in managing payer provider rosters and provider directory files.

7. Ability to communicate effectively both verbally and in writing.

8. Ability to gather reporting information regarding licensure, certification, credentialing and compliance.

9. Ability to establish and maintain effective working relationships with all levels of personnel

10. Ability to problem solve and engage independent critical thinking skills.

11. Ability to maintain confidentiality relevant to sensitive information.

12. Ability to prioritize work demands and work with minimal supervision.

13. Ability to maintain regular and punctual attendance.

EDUCATION AND EXPERIENCE:

High school diploma or equivalent required. Associate or bachelor's degree in a healthcare or business related field preferred. Minimum of six (6) months credentialing experience or one (1) year healthcare experience preferred. Experience in PHO Managed Care Contracting and Credentialing preferred.