Job Description

· Credentialing Healthcare Providers:

· Verify the qualifications and professional credentials (licenses, certifications, education, etc.) of healthcare providers (doctors, nurses, clinics, etc.).

· Ensure all providers meet the standards and requirements set by insurance companies, government programs (like Medicare/Medicaid), and other payers.

· Credentialing Application Processing:

· Assist healthcare providers in completing credentialing applications and ensuring all required documentation is submitted.

· Ensure that applications are complete, accurate, and meet all necessary criteria to avoid delays or rejections.

· Verification of Provider Information:

· Verify important provider details, such as medical licenses, board certifications, educational history, work experience, malpractice history, and other relevant qualifications.

· Confirm that healthcare providers have a clean record and no history of disciplinary actions.

· Maintain Provider Records:

· Maintain and update accurate records of credentialed providers, ensuring that all required documentation is current and stored securely.

· Track expiration dates for licenses, certifications, and other credentials to ensure timely renewal and uninterrupted participation in payer networks.

· Manage Payer Enrollment:

· Submit applications and documentation to insurance companies or other payers for healthcare provider enrollment.

· Ensure providers are properly enrolled in payer networks, allowing them to be reimbursed for services provided to insured patients.

· Monitor Credentialing Status:

· Track and follow up on the status of credentialing and enrollment applications to ensure timely approval and avoid disruptions in provider participation.

· Communicate with both healthcare providers and payer representatives to resolve any issues or delays in the credentialing process.

· Compliance with Regulatory Standards:

· Ensure that healthcare providers comply with all applicable regulations, policies, and payer-specific requirements for credentialing and participation in insurance networks.

· Stay updated on changes to credentialing standards, healthcare regulations, and payer requirements.

· Renewal and Re-credentialing:

· Manage the re-credentialing process, ensuring that providers' credentials are renewed before expiration.

· Maintain ongoing compliance by assisting with periodic reviews and updates to ensure that all credentials remain valid.

· Assist with Discrepancies or Issues:

· Address and resolve any discrepancies, concerns, or issues that arise during the credentialing process, working closely with both healthcare providers and payer representatives.

· Maintain Strong Relationships with Payers:

· Act as the point of contact between the healthcare providers and the payer organizations to facilitate smooth communication and resolve any credentialing issues.

PURPOSE AND SCOPE:

Knowledgeable, experienced specialist responsible for initial verification for all existing and new providers to allow the practitionerto admit and treat patients atFMCNA locations. Collaborates with external credentialingagent to ensure credentialing processis completed. Ensures all provider credentialing verification is performed in accordance with regulatory and accreditation standards and FMCNA policy and procedure. Performs audits of internal FMCNA Provider Database and FMCNA provider information compiled by the external credential verification agent to ensure that credential verification is completed in a timely manner according to all regulatory and company requirements. Supports FMCNA's mission, vision, core values and customer service philosophy. Adheres to the Compliance Program, including following all regulatory and division/company policy requirements.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Under limited supervision, applies considerable credentialing knowledge and skills to perform a wide range of moderately difficult tasks and assignments requiring judgment in resolving issues and/or in making recommendations. Normally receives no instruction on routine daily work, and general instructions on newly introduced assignments
• Contacts are frequently with individuals representing other departments, and/or representing outside organizations. Contacts involve obtaining or providing information or data on matters of moderate importance to the function of the department or which may be of a sensitive nature.
• Perform provider credentialing verification tasks to facilitate compliance with Medical Staff by-laws regardingthe verification of a minimum set of a practitioner's credentials required prior to the patient receiving their second treatment. Responsiblefor tasks related to the three year cyclical verification process of all active practitioners.

• Apply knowledge regarding national accreditation standards, internal medical staff bylaws and other related policies and regulations to perform functionspertaining to the provider credentialing process for the assigned division. This includes but is not limited to:

  • Obtaining practitionerlicense information from publicly available state/government agency websites, the National Provider Databank, and other 3rdparty certification groups such as the American Board of Internal Medicine.
  • Completing and processing all initial credential applications for new providers/practitionersand credential verification applications for existing providers in a timely and accurate manner.
  • Conducting follow-up as needed, acting as the primary liaison for FMCNA locations, practitioners, and the FMCNA third-party credentialing agent to ensure that all credentialing is completed within the required timelines and that each provider meets federal and state regulations as well as FMCNA internalrequirements.
  • Maintaining and updating the database on individual provider credentials' status, tracking pending/completed applications, and maintaining a complete and accurate database of historical applications. Provides regular reports and updates to pertinent field operations managementand Director of Operations Monitoring.
  • Communicating with providers regarding credentialing status, providing updates and obtaining additional information as required.
• Educate and inform field staff responsible for reporting new providers regarding their responsibilities in the credential verification process. Explain the credentialing requirements, provider specific information, informationregarding the FMCNA third-party credential agent, regulations and industry standards for credentialing of health care providers and other information as applicable.
• Continually audit and analyze the credentialingprocess to identify deficiencies in controls and to identify process/workflow issues recommending improvements to managerand implementing if approved.
• Review internal Provider Databaseinformation and databaseof FMCNA provider informationcompiled by external credential verification agent to identify and take appropriate action where requiredto correct areas of noncompliance with company policy. This includes reporting to the appropriate stakeholders identified deficiencies in provider applications, providing information regarding providers non-compliant with verification policies, notifying the appropriate personnel regardingexpired board certifications, and other requirementsituation updates as applicable.

• Generate various standard and ad hoc reports from database:

  • Prepare project status reports as required, detailing progress of credential verification status of individual practitioner credential applications for each division, and reporting variances and trends in the credentialing processas identified to the Director of OperationsMonitoring.
  • Prepare reports detailing credential verification issues to pertinent field staff and credentialverification agent.
  • The monthly provider credentialing status report for review by the Director of Operations Monitoring.
• Review and comply with the Code of Business Conduct and all applicable company policies and procedures, local, state and federal laws and regulations.
• May escalate issues to supervisor for resolution, as deemed necessary.
• Assist with various projects as assigned by direct supervisor.
• Other duties as assigned.

Additional responsibilities may include focus on one or more departments or locations. See applicable addendum for department or location specific functions.

PHYSICAL DEMANDS AND WORKING CONDITIONS :

• The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

  • Day to day work includes desk and personal computer work and interaction with internaland external customers.

EDUCATION :

• High School Diploma required; Associates Degree in Business, HealthCare Administration, or other related field desirable.

EXPERIENCE AND REQUIRED SKILLS:

• Minimum 2 - 4 years' experience in credential verification or in a Physician practice/Medical office or other similar experiencein a healthcare setting; or Associates Degree in Business,HealthCare Administration, or other related field with 1 - 2 years' experience.
• Strong detail orientation required, with the ability to administer multiple tasks and prioritize.
• Excellent verbal and written communication skills.
• Ability to positively interact with providers, hospital personnel, and other internaland external contacts.
• Perform work at a high level of accuracy and timelines.
• Attention to confidentialityand regard for protecting confidential and sensitiveinformation.
• Advanced level skills with Microsoft Access, Excel, and Word.
• Strong problem solving and time management skills with the ability to consistently work in a fast-paced environment.
• Strong Excel, data-base management, and document storage and management skills.

EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity

Fresenius Medical Care North America maintains a drug-free workplace in accordance with applicable federal and state laws.

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