Reporting to the Operations Team Lead, the Credentialing/Authorization Specialist will develop and maintain a data-base for tracking all data required by MCO's MaineCare Medicare and Private Insurances. The specialist will provide support and assistance to providers to ensure renewal applications for certifications are completed on time and meet federal and state regulatory requirements. The Specialist will also complete Continued Stay Reviews through KEPRO for assigned providers to ensure authorizations are in effect for services being delivered.
ESSENTIAL JOB FUNCTIONS:
Demonstrates commitment to the mission of the agency with a strong understanding and respect for the goals of agency activities.
Evaluate information on initial/renewal insurance credentialing applications and verifying for completeness and accuracy.
Maintain records of applications and verification letters.
Act as a liaison between the agency and various insurance groups and will maintain an application and verification data-base of affiliations and renewals dates.
Registers new providers through the Managed Care Organization (MCO), MaineCare, Medicare, and Private Insurance.
Professionally handles telephone and written inquiries related to core duties of this position.
Updates the staff maintenance menu in electronic medical record (EMR) with credentialing information.
Completes required MCO registrations and authorizations in a timely and accurate manner.
Identifies KEPRO authorizations that are about to expire prior to the next consumer visit and initiates requests for additional authorizations as needed.
Establishes collaborative relationships with third-party insurers.
Researches information with third-party vendors and navigates through the insurance industry.
Coordinates and follows up with clinical staff to ensure completion of required credentialing documentation.
OTHER DUTIES AND RESPONSIBILITIES:
Functions in a cost effective manner with regard to the utilization of time, mileage, phoning, supplies, equipment, meetings, etc.
Participates in scheduled meetings, supervisory sessions, staff meetings, and other inter-agency and intra-agency meetings as appropriate for program and position.
Seeks additional consultation and/or supervision when needed and as appropriate.
Promotes a positive agency image to staff and community.
Ensures consumer confidentiality is maintained at all times and in accordance with federal, state, and agency standards.
Completes and submits accurate, neat, legible time sheets, logs, forms and reports in a timely manner and according to policies and procedures.
Participates in training to maintain or enhance job skills.
Adheres to agency Risk and Safety policies and procedures.
Adheres to organizational standards for performance (see attached).
Performs other related duties, as requested.
High school diploma/GED and computer proficiency are required. Related work experience processing claims with Medicare, MaineCare, and commercial insurances highly preferred. Experience with Cerner software or obtaining pre-authorizations prior to treatment is highly preferred.
Thorough knowledge of modern office practices and procedures, including the use of computers, fax machines, and other general office equipment.
Ability to work independently, handle multiple tasks, and meet deadlines with a high degree of accuracy.
Strong organizational skills.
Professional demeanor, with a customer focus and strong customer service skills.
Ability to communicate effectively both verbally and in writing; to establish effective working relationships with other agency personnel.
Ability to maintain confidentiality.
Must be a team player and accountable for results.
Strong research skills to gather pertinent information regarding credentialing requirements.
WORKING CONDITIONS/PHYSICAL DEMANDS:
Normal office environment, not subject to extremes in temperature, noise, odors, etc.
May spend extended periods at terminal, on telephone, or operating other office machines, requiring eye-hand coordination and finger dexterity.
More than half of time spent in normal office setting.
*External and internal applicants, as well as position incumbents who become disabled as defined under the Americans With Disabilities Act, must be able to perform the essential job functions (as listed) either unaided or with the assistance of a reasonable accommodation to be determined by management on a case by case basis.
This job description does not constitute an employment agreement between the employer and employee, and is subject to change by the employer, as the needs of the employer and requirements of the job change.