Credentialing and Enrollment Coordinator (FT, Days)

Jefferson Health; Philadelphia (Philadelphia County); Hybrid; USD 60,000 - 90,000; Full time

Job summary

Jefferson Health is seeking a Credentialing & Enrollment Specialist to manage credentialing and enrollment of Jefferson Medical Group physicians with commercial and government payers. You will ensure documentation is complete and accurate for timely submissions.

The role supports the Delegated Credentialing team, performs primary source verification, maintains databases, tracks applications, and communicates with payers to resolve holds and status updates in a fast-paced environment.

Qualifications

• HS Diploma required; associates degree or higher preferred.
• Minimum one year in a managed care setting.
• Understanding of NCQA and managed care plans.
• Credentialing/enrollment experience preferred.
• Experience with primary source verification of credentials.

Responsibilities

• Credentialing and enrollment of JMG physicians with commercial and government payers.
• Ensure required documentation is obtained and complete for enrollments.
• Prepare initial and recredentialing plans for providers.
• Follow up and track applications with payers.
• Update credentialing/enrollment database and verify status.

Skills

Credentialing

Enrollment

Payer contracting

CMS/PECOS

Multi-tasking

Communication skills

Microsoft Office

Education

HS Diploma

Associate degree or higher

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.
• 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 and Education

• 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

• 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

Work Shift: Workday Day (United States of America)

Worker Sub Type: Regular Employee

Entity: Thomas Jefferson University

Location

Primary Location Address: 1101 Market, Philadelphia, Pennsylvania, United States of America.

About Jefferson

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.

Benefits

• 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 diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

Equal Opportunity

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.

Culture and Community

In keeping with Jefferson's Mission, We Improve Lives, it is our goal to recruit, retain, develop and reward highly-qualified employees. If you are enthusiastic, caring and dedicated to service excellence, we invite you to consider joining Jefferson. Jefferson encourages its employees to expand their knowledge and develop their careers through growth opportunities and continuing education. With a long standing history, Jefferson has been advancing the medical field from the heart of Center City Philadelphia for nearly 200 years. Our Mission, We Improve Lives, expands to every corner of the organization. From our weekly farmer’s market, to our new Jefferson Accelerator Zone for innovation, our employees’ passion for the community is evident by the daily gestures towards our patients, students and each other.