Credentialing & Enrollment Representative

This is a fully remote position, open to applicants in California.

📋 Description

• Facilitate the enrollment of providers with health plans by accurately completing and submitting enrollment applications to payors promptly.

• Comprehend and oversee various health plans, including CAQH, Medicare, Medicaid, Managed Care, and Commercial Plans.

• Identify re-credentialing dates and execute the re-credentialing process for providers and clinics.

• Manage enrollment data and follow up with health plans using centralized client spreadsheets.

• Create and refresh CAQH records on a quarterly basis.

• Input, update, and sustain provider application data within the credentialing database.

• Ensure provider demographic information and NPPES records are current.

• Prepare agendas and contribute to client calls and internal meetings.

• Prepare, monitor, and follow up on verifications for high-volume provider applications.

• Oversee files for completeness, accuracy, quality standards, accreditation requirements, and policy adherence.

• Recognize, analyze, and rectify discrepancies impacting credentialing and enrollment.

• Provide insights and updates regarding credentialing and health plan enrollment.

• Engage with providers, liaisons, medical staff leadership, Administration, colleagues, management, and health plans.

• Proactively detect issues, resolve credentialing challenges, and report concerns to management.

• Maintain accurate and current provider and credentialing information for both initial and re-credentialing.

⛳️ Requirements

• Bachelor's degree in Healthcare Administration, Business, Finance, or a related discipline (preferred).

• A minimum of 2 years of full-time experience encompassing all aspects of credentialing, including provider interactions.

• Familiarity with Medicare, Medi-Cal, Managed Care, and Commercial insurance options.

• Proficient understanding of enrollment terminology.

• Strong knowledge of Federally Qualified Health Centers (FQHCs) and Community Health Centers (CHCs).

• Excellent ability to collaborate with cross-functional teams.

• High accuracy level and capability to set and maintain priorities in a dynamic environment.

• Strong proficiency in Microsoft Excel, Word, and Outlook.

• Capacity to adapt to changes in regulations, technologies, and industry trends.

🏝️ Benefits

• Comprehensive health benefits package.

• Opportunities for professional development and career advancement.

• Supportive work environment with a focus on teamwork.

• Flexible working hours and potential for remote work options.