Credentialing Coordinator

Vision 

To level the playing field between dental practices and insurance companies nationally; while building lifelong relationships with clients & teammates built on mutual trust, respect and exceptional performance. 

Mission 

Dental practices that participate with insurance groups find their margins shrinking every year. Our mission is to help dental practices navigate through the muddy waters caused by the TPA’s, to gain a competitive advantage through strategic planning optimizing each provider’s network participation with flawless execution and training. 

Our Prime Directives 

1. Recruit & Hire extraordinary people who are willing and motivated to become part of a team [ family ] and will embrace the culture that inspires trust, confidence, respect and accountability.
2. Attract Responsive, Respectful and Receptive [ the 3 R’s] clients that trust and value the knowledge and results PNS offers leading to referrals of like minded dentists.
3. Provide the tools, training and support from a leadership team that is respectful and provides continuous opportunities for professional and personal development.

Credentialing Coordinator Job Summary 

• The credentialing coordinator position requires an organized, detail–oriented Individual. In this role, you will process Standardized Credentialing Application, termination and OPT OUT forms for potential healthcare providers; as well as, conduct Verification calls to validate how each provider’s NPI is being picked up by various TPA’s. You will also verify that each provider’s application information is accurate and not expired. 
• This role is essential to preserving the confidentiality and safety of our patients, so you must follow all federal and state regulations as well as internal policies. 
• We Level the playing field between insurance companies and practices 

Duties and Responsibilities 

(1)Credentialing: 

• Negotiate and manage multiple complex payer fees with insurance companies on behalf of PPO Negotiation Solutions [PNS]. 
• Work independently to draft, review and revise proposed contracts and other related documents, ensuring compliance with company policy/guidelines and legal and regulatory requirements by working collaboratively with internal and external clients. 
• Develop relationships by collaborating with internal departments to successfully meet department and strategic goals. 
• Process credentialing applications, term letters, OPT OUTS and any supporting documentation 
• Preserve the confidentiality of patient information and records through proper credentialing. 
• Ensure all licenses such as professional licenses, certifications, DEA, and Liability Insurance are not expired. 
• Maintain accurate information for all providers. 
• Work cross–functionally with PPO Project Managers across the company in every function to orchestrate, execute & deliver the “Final Strategy” in a seamless manner and error free. 
• Utilizes Asana project management software effectively to monitor and track the progress of each project; Adjusting on occasion when unexpected events occur within the project “Final Strategy.” 
• Communicate with the providers to gather, review and provide guidance on completion of complete credentialing packets. Also, coordinates the accurate input of provider’s information into CAQH and 
• Medicare, Medicaid database when the project details call for it. 
• Contact appropriate organization members on any changes or obstacles that present during the Project. 
• Update the appropriate departments on the status of the provider’s credentialing process. 
• Assists the team to create and update training materials. 
• We Level the playing field between insurance companies and practices 

(2) Verification Calls 

• Verification calls for collecting data for each provider in a new project. It is important to try to get the most accurate information for each provider to allow the PPO Project Manager to maximize the correct insurance to increase the client’s earning potential. The following items are necessary for the data collected for the verification calls. 
• Rep Name 
• Confirmation number (if available) 
• Is the provider(s) in a direct contract? – each doctor in a project will need to be verified. 
• Is the direct contract under the practices group EIN or the provider’s Individual NPI? 
• Which fee schedule is the doctor(s) assigned to? If multiple providers, are they on the same fee 
• schedule? 
• What is the effective date the doctor(s) application, termination or OPT OUT? 
• Request a copy of the current fee schedule. 
• Is the provider(s) in a rented network? (Under the group EIN/Individual NPI? 
• Is the provider shown at any other address?

** Some plans will require information for which plans the provider(s) are enrolled in under the 

specific insurance 

(3) Audit Calls: 

• Make audit calls to follow up on effective dates for the following, when assigned by PPO Project Manager.. 
• PPO Project Manager will specify the specific information needed for each verification call: 
• Confirm that the application/term/opt out was received and is being processed. 
• Confirm the effective date of application/term/opt out. 
• Verify which insurance they see the provider(s) claims being paid. 
• Update accurate information in Asana/Mapping Project. 
• We Level the playing field between insurance companies and practices 

Requirements: 

• Must possess demonstrated skill in problem analysis and resolution; contract management; oral and  written communication. 
• Requires problem solving skills and complex decision–making skills. 
• Requires highly developed interpersonal and listening skills. 
• Must be detail oriented. 
• Exceptional time management skills to keep the project on course and meeting the project deadline. 
• Must be able to function independently and possess demonstrated flexibility in multiple project management. 
• Experience in negotiations is a plus. 
• Possess the interpersonal skills to interact effectively and cultivate supportive relationships with internal customers, managed care payors, consultants, outside agencies, and internal/external corporate executives. 
• Ability to manage all contractual aspects of major projects. 

Competencies 

• High school diploma or GED certificate 
• Associate degree (strongly preferred) 
• Credentialing or healthcare administration experience 
• Computer proficiency 
• Excellent written, proofreading, and verbal communication skills 
• Minimum Typing speed of 40 WPM 
• Knowledge of Google products would be a plus [ Canned Emails, Google Sheets, Google doc etc ] 
• Phone communication and organizational skills 
• Attention to detail 

Physical Requirements 

• We Level the playing field between insurance companies and practices 
• Prolonged periods sitting at a desk and working on a computer. 
• Must be able to lift up to 15 pounds at a time. 
• Will be exposed to working conditions commensurate with a remote working environment.