Managed Care Credentialing Specialist- Physician Organization (Medical Center)

Overview

At Houston Methodist, the Managed Care Credentialing Specialist position is responsible for the timely and accurate completion and submission of managed care credentialing documents for new physicians and advanced practice practitioners (APPs). Duties for this position include credentialing and enrollment in governmental and commercial managed care plans and medicare and medicaid. The Managed Care Credentialing Specialist position has consistent interaction with the new providers, Administrators, health plans (commercial and governmental), and the department.

Houston Methodist Standard

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED

Refer to departmental “Scope of Service” and “Provision of Care” plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
• INTEGRITY: We are honest and ethical in all we say and do.
• COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
• ACCOUNTABILITY: We hold ourselves accountable for all our actions.
• RESPECT: We treat every individual as a person of worth, dignity, and value.
• EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.
• Practices the Caring and Serving Model
• Delivers personalized service using HM Service Standards
• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)
• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees’ experiential journeys to ensure strong communication, ease of access to information, and a seamless experience.
• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job
• Displays cultural humility, diversity, equity and inclusion principles
• Actively supports the organization’s vision, fulfills the mission and abides by the I CARE values

Responsibilities

PEOPLE ESSENTIAL FUNCTIONS

• Provides information to physicians and advanced practice practitioners on necessary requirements for all credentialing documents.
• Provides education for on-boarding providers and key stakeholders.
• Responds to inquiries regarding the provider’s application and information internally and externally.
• Conducts self in a manner that is congruent with cultural diversity, equity, and inclusion principles. Contributes towards improvement of department scores for employee engagement, i.e., peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Processes and maintains credentialing and re-credentialing documents into the appropriate software system by entering, logging and scanning information.
• Submits all necessary documents to governmental and commercial plans on a timely basis.
• Provides regular and ad hoc reports regarding status of credentialing documents.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Recognizes, investigates, and validates discrepancies and adverse information obtained from the application, primary source verifications, or other identified sources to ensure that review and approval bodies have the information needed to make informed credentialing decisions.
• Ensures compliance with government regulations and organizational standards and requirements.
• Performs audit of provider files annually in preparation for re-credentialing of current providers.

FINANCE ESSENTIAL FUNCTIONS

• Provides the Central Business Office and Managed Care department information when claims from commercial and governmental plans require additional information or clarification regarding credentialing.
• Ensures managed care plans receive documentation timely promptly when completed so providers can commence patient care timely.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Manages the databases continually and improves reporting and filtering capability to enable better business functions.
• Reviews software and database systems to report any discrepancies or data entry issues.
• Seeks opportunities to identify self-development needs and takes appropriate action. Ensures own career discussions occur with appropriate management. Completes and updates the My Development Plan on an on-going basis.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

Qualifications

EDUCATION

• High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)

WORK EXPERIENCE

• Three years experience with physician credentialing and/or other medical administrative-related tasks

License/Certification

LICENSES AND CERTIFICATIONS – REQUIRED

• N/A

LICENSES AND CERTIFICATIONS – PREFERRED

• CPMSM – Certified Professional Medical Services Management (NAMSS) OR
• CPCS – Certified Provider Credentialing Specialist (NAMSS)

KSA/ Supplemental Data

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through on-going skills, competency assessments, and performance evaluations
• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security
• Ability to effectively communicate with patients, physicians, family members and co-workers in a manner consistent with a customer service focus and application of positive language principles
• Must be self-motivated with excellent organizational skills to ensure ability to track and manage large volumes of documents
• Ability to manage multiple priorities and projects
• Detail oriented with desire for producing work with 100% accuracy
• Intermediate level of computer competency – Microsoft Office Suite

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*

• Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.
• On Call* No

TRAVEL**

• Travel specifications may vary by department**
• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No

Company Profile

Houston Methodist Specialty Physician Group – As one of the nation’s leading hospitals and academic medical centers Houston Methodist has brought together some of the nation’s leading experts in multiple specialties to serve our patients. As part of Houston Methodist Specialty Physician Group (HMSPG), these specialists not only provide excellent clinical care, but are on the forefront of research, developing leading-edge technologies and treatments, and teaching the medical pioneers of tomorrow. This combination of clinical service, research and academics ensures patients have access to the latest in treatments and technologies while providing the best in comprehensive patient care. Established as a non-profit corporation and certified by the Texas State Board of Medical Examiners, HMSPG enables physicians to maintain autonomy with respect to their clinical practice while growing their practice within an academic environment.

Equal Employment Opportunity

Houston Methodist is an Equal Opportunity Employer.

Equal employment opportunity is a sound and just concept to which Houston Methodist is firmly bound. Houston Methodist will not engage in discrimination against or harassment of any person employed or seeking employment with Houston Methodist on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, status as a protected veteran or other characteristics protected by law. VEVRAA Federal Contractor – priority referral Protected Veterans requested.

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