Provider Enrollment & Credentialing Representative

Overview

Summary Reports to the Supervisor, Provider Enrollment & Credentialing
. Responsible for the timely completion of all initial and re-credentialing processes, as well as payer enrollments, for Beacon Health System
. Coordinates with physicians, providers, credentialing agencies, regulatory bodies, payors, office managers, and contracted providers to ensure credentialing and enrollment activities comply with National Committee on Quality Assurance (NCQA) standards and departmental policies and procedures.

MISSION: We deliver outstanding care, inspire health, and connect with heart.

VALUES: Trust. Respect. Integrity. Compassion.

SERVICE GOALS: Personally connect. Keep everyone informed. Be on their team.

• Ensures timely completion of credentialing activities in compliance with NCQA and departmental standards.
• Coordinates with external agencies, payors, office managers, and contracted providers to complete credentialing requirements.
• Acts as a liaison with Medical Directors, Hospital Medical Staff, and internal/external stakeholders regarding credentialing status.
• Performs Primary Source Verifications per applicable accreditation standards (JCAHO, AAAHC, URAC, etc.).
• Conducts online verifications and reviews relevant credentialing resources.
• Notifies appropriate entities of provider effective and termination dates.
• Communicates with the Physician Recruitment team regarding provider onboarding and credentialing status.
• Maintains regular follow-up with providers and communicates status updates to ensure credentialing completion prior to start dates.

• Ensures timely completion of all payer enrollment activities per payer requirements and departmental procedures.
• Completes insurance and government applications on behalf of Beacon Health System providers.
• Alerts management of any delays or non-compliance issues.
• Maintains accurate and up-to-date data in credentialing software systems.
• Provides timely reports as needed.
• Manages and updates each provider’s CAQH online profile.
• Applies for and maintains Beacon Health System provider NPPES (National Plan & Provider Enumeration System) identifiers.
• Assists Beacon Medical Group and hospital Patient Accounts departments with network and claims issues related to credentialing.
• Adheres to strict follow-up schedules, ensuring all credentialing and enrollment steps are completed before provider start dates.

• Attends and participates in department meetings; accountable for all information shared.
• Completes mandatory education, annual competencies, and department-specific training within required time frames.
• Complies with annual employee health requirements and organizational/departmental policies.

• High school diploma or equivalent required;
  Associate’s Degree in Business, Health Administration, or a related field preferred.
• Minimum of three years of credentialing experience or equivalent experience in healthcare or health insurance preferred.

• Working knowledge of federal, state, and local laws and NCQA standards applicable to credentialing and enrollment.
• Strong analytical, problem-solving, and organizational skills to enhance and streamline credentialing processes.
• Proficient in Microsoft Office Suite and standard office equipment.
• Excellent written and verbal communication skills.
• Strong interpersonal skills to build and maintain effective relationships with internal and external stakeholders.

• Primarily office-based environment.

• Requires physical ability and stamina to perform the essential functions of the position.