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Under the general direction of the Manager or designee, the Credentialing and Contract Specialist will serve as an integral member of the Program and with limited oversight to ensure provider contracts are executed and credentialing applications are finalized. The Credentialing and Contract Specialist  will identify and compile required information necessary to analyze and process provider contracts after credentialing requirements have been met and completed. This position will track and log all completed contracts, maintain provider/vendor contracts and Credentialing files for the Program.

This position is a key contributor in communicating with over 100 medical and psychologist providers and maintaining up-to-date licenses and insurance. The Credentialing and Contract Specialist  is also responsible for reviewing, analyzing and managing provider contracts and for keeping billing and scheduling department updated with current provider status. This position will have responsibility for the implementation and renewal of provider contracts and reappointment applications, verification of current licensure, malpractice insurance and other related requirements. 

MAJOR RESPONSIBILITIES:

Credentialing:

• Coordinate the credentialing processes for network providers to ensure all required documentation and information is prepared and available for final determination.
• Perform all duties necessary to operate a credentialing program that supports initial appointments and reappointments.
• Establish and maintain professional relationships with provider personnel to ensure provider information is current.
• Review provider credentialing information for accuracy and completeness and follow-up in a timely fashion with providers, references and other sources to obtain missing information.
• Assist with the recruitment of new providers and initiate credentialing process for all new provider applicants.
• Ensure all new applicants are properly entered into federal databases.
• Communicate any potential issues with a provider to the Senior Director and Medical Director prior to completing the credentialing process.
• Initiate, design and revise all credentialing related forms and letters.
• Conduct required site visits for credentialing of new providers.
• Responsible for preparing and distributing required provider information for the review and final determination by the Peer Review Committee, which is comprised of the Medical Director and Physician Advisor staff.
• Oversee the provider disenrollment process, including maintaining a tracking mechanism for inactive providers
• Communicate provider information updates and disenrollment to Senior DES staff as appropriate

Contracting:

• Oversee all contract development and management activities related to provider contracts and vendor contracts within the Program.
• Create and maintain a detailed and organized contract tracking system, which allows for accurate and timely follow-up and problem resolution. Track the status of contracts and time-lines and inform Manager of variances.
• Create new contracts and amendments using the Office of Compliance and Review approved contracts forms for services purchased and for newly approved provider credentialing applications.
• Responsible to ensure that all new contracts are properly entered into organizational databases, securely maintained, and properly executed to confirm billing is timely.
• Interpret contract language and ensure that the terms of contracts are communicated and implemented accurately within our system
• Responsible for renewing expired DES contracts and creating amendments to existing contracts.
• Prepare all legal contract forms for each individual provider and/or group practice.
• Coordinate implementation of executed contracts with scheduling unit.
• Perform related duties as assigned.

REQUIRED QUALIFICATIONS:

• Bachelor’s Degree in Business Administration, or a related field; or equivalent.
• 3 years of related professional experience.
• Working knowledge of database, spreadsheet and word processing software.
• Previous experience with maintaining federal credentialing databases.
• Previous experience with the initiation and execution of contracts.
• Excellent communication skills, problem-solving skills, and strong interpersonal skills to liaise with medical professionals and administrators.
• Team player with proven ability to develop strong working relationships
• Ability to travel to site locations as needed.

PREFERRED QUALIFICATIONS:

• Extensive experience with contract initiation /execution and provider credentialing
• Superior problem solving, decision-making, contract language and credentialing skills

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