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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.

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.

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

LICENSES AND CERTIFICATIONS - REQUIRED

• N/A

LICENSES AND CERTIFICATIONS - PREFERRED

• CPMSM - Certified Professional Medical Services Management (NAMSS) OR

• CPCS - Certified Provider Credentialing Specialist (NAMSS)

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 is an integral part of Houston Methodist’s overall strategy to become one of the nation’s leading academic medical centers. Established as a nonprofit corporation certified by the Texas State Board of Medical Examiners, the Specialty Physician Group enables physicians to maintain autonomy with respect to clinical practice while growing their practice within an academic environment.

Houston Methodist is an equal opportunity employer inclusive of women, minorities, disabled persons and veterans.

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.

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.