Contract and Credentialing
Job Summary:
Oversees the management of outside vendor contracting services for the provider network for the PACE Program. Oversees the credentialing process for contracted providers.
Qualifications and Requirements:
Experience:
- Minimum of 1 year working with the frail or elderly.
Skills and Knowledge:
- Knowledge of professional and institutional medical contracts including their credentialing and regulatory statutes.
- Ability to establish and maintain effective working relationships with outside medical vendors and coordination of their activities with internal departments.
- Ability to negotiate effective, code definable and regulatory compliant contracts with both professional and institutional vendors on behalf of the PACE Organization.
- Must have the ability to negotiate contracts and manage outside vendor contracts and maintain them in consolidated managed care system.
- Ability to coordinate all credentialing activity between contracted vendors and internal and external credentialing review entities
- Exceptional verbal and written communication skills with computer skill sets specific to the gathering of information from the Internet.
- Ability to communicate and present information in a concise and positive manner in order to promote the PACE Organization in a positive light.
- Ability to establish priorities, coordinate work activities and work independently.
Physical Demands and Working Conditions:
The physical demands and work environment characteristics described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. In compliance with ADA requirements, reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.
Work Environment:
Employee must be able to work effectively within an interdisciplinary team model, interfacing and collaborating with a wide range of clinical and social services disciplines who work together to manage the PACE participants’ care. The work setting is in an Adult Day Health Center and primary care clinic environment with moderate noise levels and controlled temperatures.
Physical Requirements:
Requires manual and finger dexterity and eye-hand coordination; the ability to use department equipment; and the ability to lift/carry up to 30 pounds using appropriate body mechanics with reasonable accommodation if needed.
Visual, Hearing and Communication Requirements:
Requires corrected vision and hearing to normal range, with or without reasonable accommodation. Ability to communicate by way of the telephone with participants, customers, vendors and staff.
Pressure Factor:
Requires working under stressful conditions. Working conditions may be noisy and crowded and fluctuating indoor temperatures. Moderate pressure to meet scheduled deadlines. Potential for exposure to verbal aggression by client, vendors, and staff.
Environmental Conditions:
May be exposed to a risk of bodily injury through contact with moving instrumentation, toxic substances, medicinal preparations, bodily fluids, communicable diseases and any other conditions common in a healthcare environment. Subject to unpleasant odors.
Duties and Responsibilities:
- Develops contractual relationships with service providers, such as negotiating rates, drafting contract agreements, and maintaining provider network listings
- Works with Director of Quality Assurance and Compliance Officer to coordinate quality assessment of potential providers.
- Creates Out of Network and HIPAA business agreements, as needed.
- Serves as the credentialing coordinator for contracted providers.
- Serves as the liaison between the contracted credentialing verification organization, the PACE Organization.
- Ensures contract compliance and credentialing compliance with State and Federal regulations.
- Tracks and updates contractor files with current medical licenses, facility state licenses, registrations, DEA license, and certificates of liability insurance, state surveys.
- Conducts initial meetings with possible providers to educate them about contractual process.
- Conducts appropriate follow-up with pending providers to ensure timely implementation of contracts.
- Provides the initial provider orientation training to all contracted providers. Ensures that all attestations and receipts are signed and filed.
- Provides updated annual training material to contracted providers.
- Manages provider directory to ensure information is updated in a timely manner per PACE regulations.
- Develops necessary policies and procedures related to network development and credentialing.
- Interfaces with organization’s departments and maintains a provider database to communicate appropriate contract information, including responsibility for updating provider information in the PACE Organizations.
- Conducts initial credentialing and re-credentialing of applicable providers or delegates to an outside credentialing agency.
- Monitors applicable websites monthly and as needed for disciplinary summaries from the Board of Medical Examiners, as well as excluded providers from Medicare and Medicaid (OIG).
- Participates in onsite monitoring as required by the QA Director and Executive Director.
- Identifies, analyzes, and resolves work problems.
- Follows all Policies, Standard Operating Procedures and OSHA safety guidelines.
- Maintains the confidentiality of all company procedures, results, and information about patients and clients including faxed information and courier materials.
- Maintains safe working environment. Follows all fire and safety guidelines.
- Participates in continuing education classes and any required staff and training meetings.
- Maintains professional affiliations and any required certifications.
- Performs other duties as required or requested.