Provider Coordinator (52303) at GlobalHealth, Inc.

Who We Are

GlobalHealth is a fast-growing Medicare Advantage HMO health insurer. We aspire to be the employer of choice in our industry, attracting and retaining a highly talented workforce. Our passion is Genuine Care and Optimal Health for the members we serve. We are unique by providing high touch, high value and a partnership to our members. We go above and beyond to provide personalized, engaging, and responsive services to our members. We work hard to offer affordable health insurance coverage with the benefits people truly want and need. It is our hope to be more than just a health insurance company we want to be long-term partners with our members. We are looking for future employees who exude our core values of taking accountability through ownership, being driven, innovative and who have a passion for continuous learning.

Who You Are

The primary goal of the Provider Coordinator is for quality assurance of the provider data integrity, for responses to provider inquiries with research and resolution, and to ensure proper categorization of provider directory. This role supports credentialing and provider relations activities while ensuring the accuracy, timeliness, and compliance of the provider directory. This role partners cross-functionally to maintain data integrity and meet CMS regulatory requirements for provider data accuracy and accessibility.

Essential Job Functions

• Verify Provider Data integrity with on-going monitoring and responds to daily inquiries in a timely manner.
• Assists in maintaining accurate Provider/Vendor records and Provider Directory
• Educate and assist providers to maximize data integrity and provider experience.
• Actively participates and assists in meeting CMS guidelines.
• Responses, researches and resolves Provider Inquiries within JIRA and other sources.
• Serves as a point of contact for provider data updates and corrections.
• Coordinate initial and recredentialing processes for providers in accordance with OK and CMS standards.
• Tracks credentialing timeliness and ensure compliance with turnaround requirements. Processes applications and credentialing paperwork, checking for completeness and accuracy.
• Obtains primary source verification of competencies relating to the applicant such as relevant board certifications, health facilities affiliations, licensure, certifications, DEA, OBNDD certificates, and malpractice coverage following GlobalHealth Credentialing Policy and Procedures including CMS requirements.
• Queries and processes of primary source verification, verification, and accreditation information including NPDB, OIG, SAM, and Medicare Opt Out.
• Emails, faxes, or mail provide communications.
• May prepare credentialing files and submit practitioner and provider information to Credentialing Committee for approval in timely manner.
• May support review of credentialing files and databases for both practitioners and providers. Maintains communication with appropriate practitioners to ensure records are up-to-date and consistent.
• Notifies practitioners and providers of Credentialing Committee decisions and renewal dates and responds to request for status of credentialing.
• Manages, requests and follows up expirable as needed (license, COI, Board Certifications, etc).
• Collaborate on outreach to providers for data validations.
• Coordinates with delegated vendors to validate provider data accuracy and timelines.
• Support oversight of delegated entity credentialing rosters, and other notifications related to directory accuracy and credentialing timelines.
• Maintains confidentiality of all credential files.
• Completes various work assignments as requested by supervisor in a timely manner.
• Maintains current desk procedures and reference materials.
• Must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy.
• Performs other duties as assigned.

Qualifications

EDUCATION AND EXPERIENCE

• High School diploma or equivalent required
• Three to five years of credentialing experience
• Ability to manage multipole priorities and meet deadlines in a fast-paced environment.
• Knowledge of CMS, NCQA and state regulatory requirements related to provider credentialing and directory accuracy.

Skills

KNOWLEDGE, SKILLS AND ABILITIES:

• Computer Proficiency Demonstrated proficiency in the use of personal computer applications; specific skills to include Microsoft Word, Outlook, Excel v-lookup, and ability to build and compare files.
• Interpersonal Skills Ability to quickly develop rapport and work effectively and professionally with all levels of personnel.
• Critical Thinking Skills Ability to investigate/research problems and issues and to recommend associated corrective actions.
• Discretion Ability to manage sensitive or confidential information in a professional and discreet manner.
• Exercises judgment when dealing with applicants by demonstrating the ability to analyze.

situations and use tact and diplomacy to arrive at resolutions.

• Proper organizational/time management skills
• Preferred experience with Medicare Advantage plans
• Working knowledge of credentialing processes and guidelines primary source verification and
• Knowledge of types of modalities, specialties, and education required for each practitioner and provider
• Strong verbal, written and organizational skills must be self-directed/initiative-taking and must have analytical, problem-solving and decision-making abilities.
• Must have the following mental abilities: Alertness, precision, analytic ability, problem solving, memory, communication, creativity, concentration, judgment, imagination, initiative, resilience to push through barriers to the solution.

Work Environment

Current work environment is remote, however, some state exclusions apply.

Must have access to a reliable and secured internet connection source. Work environment must maintain confidentiality of business information, including Protected Health Information (PHI), as required by HIPAA and company policy. This position will also be required to use reasonable and necessary safeguards to protect GlobalHealth records from unauthorized access, disclosure or damage and will adhere to all GlobalHealth privacy and security policies.

Travel

No travel required.

Supervisory Responsibility

This position is not a supervisory position.

Other Duties

This job description is not intended to include a complete list of all activities, duties, or responsibilities required of the employee. Duties, responsibilities, and activities may change at any time, with or without notice.