Performs ongoing provider file database maintenance, modification and Qcare contract linkages for all Emblem Brands (i.e. HIP, GHI HMO, GHI PPO). Conducts all processes related to provider file maintenance in accordance with established EmblemHealth policies/procedures and in compliance with all applicable regulatory agencies (NCQA, NYS, CMS, etc). Provides technical support to all aspects of physician reimbursement
In order of significance, list up to 6-8 of the main tasks performed regularly to fulfill the basic function of the job. Each accountability should begin with an action verb (e.g., design, manage, implement, develop, evaluate, administer, coordinate).
• Maintains CPF Provider Database. Tracks and executes provider file updates. Provides timely, effective and accurate responses to provider data issues raised by providers, according to established departmental thresholds.
• Management of work inventory via self-directed access to team work queue (email Queue) and management of personal work queues. Queue will contain requests received from internal and external (i.e. Providers) customers. Retain completed work and request documents in EDM/Softheon.
• Use of CMORE document retrieval system to access documentation to support IPA(provider group specific configuration/rates)
• Use of QCARE and/or MCS-COREPROD to review/confirm correct provider data uploads to these systems
• Creating/activating new directly-credentialed providers and their locations utilizing the list of approved providers from the CRC (Credentialing/Recredentialing Committee.
• Creating/activating/terminating/maintaining delegated providers/locations via files received from entities using Provider Dataset
• Creating/activating/terminating/maintaining hospital based providers/locations via files received from providers
• Adding/inactivating locations
• Making requested demographic changes
• Completing provider terminations and ensuring applicable provider checklists and letters are generated
• Completing provider reinstatements (when providers reverse their termination decisions)
• Creating/activating/maintaining Professional Organization provider records
• Completing provider location updates that require providers to be added into or removed from product/network participations (i.e. Opt-Ins/Opt-Outs)
• Competing credentialing status changes
• Completing provider location updates that require existing par providers to be activated for newly contracted brands (collections of products/networks) commonly referred to as cross-recruitment.
• Phone outreach to providers when work items require clarification or additional documentation.
• As needed, assists in translating physician contracts to the appropriate CPT4 codes; subsequently loading the codes and fee schedules to the Qcare mainframe
• Communicates Emblem Health provider file policies to affiliated and non-affiliated providers.
• Provides representation to the provider community on behalf of the Department, to respond to requests for assistance with issues relating to reimbursement, issues requiring internal Emblem Health coordination and enhancements to existing communications to groups. Direct phone communication with providers when clarification or follow-up is needed for any requests.
EmblemHealth - 30+ days ago
EmblemHealth is set on being the mark of good health in the Northeast. The not-for-profit company provides health...