Representante de Credencializacion

Regular

Non-Exempt

GENERAL DESCRIPTION:

Responsible for soliciting, collecting, and validating documents necessary for the credentialing and re-credentialing of participating healthcare professionals and facilities in the MCS provider network for all lines of business, following the requirements of Industry regulatory agencies and Credentialing Policies and Procedures.

ESSENTIAL FUNCTIONS:

• Requests, collects, and validates documents required for the credentialing and/or re-credentialing process of new and existing MCS network(s) providers, following established departmental policies and procedures.
• Receives, prints, stamps, and digitizes all documents received from providers either by mail, fax, e-mail, or hand delivered, as required by state and federal regulatory agencies.
• Obtains and evaluates information to ensure strict compliance with credentialing processes according to accrediting agencies and regulatory standards.
• Performs primary validations such as NPDB reports, education validations, Board validations, grievances, Medicare OPT-OUT, CMS PRECLUSION LIST, EPLS, and OIG, among others.
• Evaluates the credentialing file and assigns the Level I or II category for presentation to the credentialing committee.
• Verifies and documents expiring credentials, using acceptable verification sources to ensure compliance with accrediting agencies and regulatory standards
• Documents the entire process in the PAS Credentialing system, including specific documentation of all follow-ups, process progress, and pending documentation
• Researches and validates discrepancies and/or adverse information obtained from the application, primary source verification, or other sources to ensure that each file has all the necessary information for the Credentialing Committee’s evaluation and approval process
• Continuously and consistently modifies and updates provider credentials in the Credentialing System.
• If required, physically inspects medical offices and facilities to complete the required credentialing and recredentialing processes as needed.
• Updates provider information available in the Credentialing System with updates made in Power MHS
• Provides necessary follow-up to complete the credentialing and re-credentialing process for providers following the Credentialing Policy. In the case of Providers that represent a risk due to the impact on membership, alerts the supervisor to seek other contact or contracting alternatives that minimize the impact.
• Receives, reviews, and guides providers personally or by telephone on the credentialing and re-credentialing process, the status of applications, and/or pending documents, among others.
• Prepares, maintains, and updates provider credentialing files for evaluation by the Credentialing Committee.
• Complies fully and consistently with company standards, policies, and procedures and local and federal laws applicable to our industry, business, code of conduct, and employment practices.

MINIMUM QUALIFICATIONS:

Education and Experience: High School Diploma. Minimum two (2) years of experience performing duties in similar positions in monitoring and reporting areas, preferably in the Health Insurance Industry.

Or

Two years of education equivalent to 60 college credits or an associate degree. Minimum one (1) year of experience performing duties in similar positions in monitoring and reporting areas, preferably in the Health Insurance Industry.

Certifications/Licenses: N/A

“Proven experience may be replaced by previously established requirements.”

Other: N/A

Languages:
English – Intermediate (writing, conversation, and comprehension)
Spanish – Intermediate (writing, conversation, and comprehension)

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