Credentialing and Enrollment Coordinator (FT, Days)

Jefferson Health Plans; Philadelphia (Philadelphia County); On-site; USD 52,000 - 78,000; Full time

Job summary

Jefferson Health Plans is seeking a Credentialing Specialist to manage credentialing and enrollment for JMG physicians with commercial and government payers. You will work with department staff to obtain and verify required documentation for a smooth enrollment process.

Responsibilities include preparing applications, tracking payer status, updating databases, and assisting with primary source verification. A strong foundation in managed care and NCQA standards is essential.

Qualifications

• HS diploma required; associates degree preferred.
• Minimum one year experience in a managed care setting.
• Understanding NCQA and managed care plans required.
• Prior credentialing/enrollment experience preferred.
• Experience with primary source verification preferred.
• Knowledge of credentialing/enrollment systems (Cactus) and CPCS preferred.

Responsibilities

• Prepare initial and recredentialing plan applications for JMG physicians and other contracted providers.
• Follow up and track provider applications submitted to payers and document status.
• Process changes and terminations from departments and practices in a timely manner.
• Investigate provider claim holds and request release once payer setup is confirmed.
• Assist the Delegated Credentialing team with Primary Source Verification for JP Committee submission.
• Update credentialing and enrollment databases, maintaining data integrity.

Skills

Payer contracting

CMS/PECOS enrollment

Multi-tasking

Attention to detail

Communication skills

Microsoft Office

Education

HS diploma

Associates degree or higher preferred

Tools

Cactus

Job description

Job Details

Responsible for the credentialing and enrollment of Jefferson Medical Group (JMG) physicians with contracted commercial and government payers. Works with assigned department staff to ensuring required documentation is obtained and complete for a smooth enrollment process.

Job Description

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson
• Prepare initial and recredentialing plan applications for non-delegated and auxiliary providers for the Jefferson Medial Group (JMG) Physicians, as well as other physicians that contract with JMG.
• Follow up and track provider applications submitted to payers. Connect payers regarding status of applications and document/update the credentialing/enrollment database with status.
• Process changes and terminations from departments and practices timely
• Investigate provider claim holds, and submit request to release hold once confirmation of payer set up is received
• Assist the Delegated Credentialing team with Primary Source Verification for submission to the Jeffcare Committee meeting for approval.
• Update credentialing and enrollment database. Maintain the integrity of physician and practice information in JMG physician enrollment database and outside credentialing databases.

Required Experience, Education, Certification(s), License(s)

• HS Diploma required, Associates Degree or higher preferred.
• Minimum one year experience working in a managed care setting required.
• Understanding of National Committee for Quality Assurance (NCQA) and Managed Care Plans required.
• Prior credentialing / enrollment experience preferred.
• Experience in obtaining primary source verification of credentials preferred.
• Working knowledge of credentialing/enrollment systems (i.e. Cactus) Certified Provider Credentialing Specialist (CPCS) preferred.

Required Knowledge, Skills, and Abilities (Proficiencies):

Knowledge of payer contracting and criteria for health plans payer enrollment. Experience with CMS/PECOS provider enrollment. Ability to multi-task. Strong organizational skills with a keen attention to detail. Ability to work in high pace and high profile environment meeting tight deadlines. Ability to interact effectively with a variety of people (such as physicians and medical staff offices). Strong written and verbal communication skills. Excellent PC skills with experience using Microsoft Office Package

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow’s professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time(including per diemcolleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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