Managed Care Provider Enrollment Specialist - 1902811
The Managed Care Provider Enrollment Specialist is responsible for ensuring the enrollment and continuity of the clinical health care providers who are affiliated with Stony Brook Medicine, including the physicians of the clinical specialties administered by the Clinical Practice Management Plan, Meeting House Lane Medical Practice, PC and the clinically integrated networks participation with managed care organizations and other payers by managing the enrollment process and timely submission of required documents. The incumbent is responsible for enrollment, disenrollment and demographic changes with contracted managed care organizations, coordinating and maintaining documents required to enroll a provider with the managed care organization and internal and external audits and corrective action plans as it relates to provider demographic information.
Duties of theManaged Care Provider Enrollment Specialistmay include the following but are not limited to:
Responsible for the data intake, collection and accuracy of individual clinical health care provider demographic data and supporting documentation required to enroll provider in a managed care organization network. Once a network provider, ensure continuity of the clinical health care provider by submitting demographic data or supporting documentation. Notifies managed care organization and other payers of practice location changes, phone and other licensure or certification changes, inaccurate information in managed care organization or other payers systems and directories.
Via delegated credentialing electronic roster or other format, transmit information, data and documentation to managed care organizations and other payers within established guidelines for turnaround time and in accordance with department policies and procedures and external requirements (delegated agreement, federal or state).
Coordinates timely enrollment and transaction activities and communication with central departments and sites to ensure consistency and accuracy. Follow-up with managed care organization or other payer representative to facilitate prompt completion of enrollment. Handles enrollment issues and exceptions and resolves issues. Escalate to supervisor when needed.
As it relates to the Delegated Credentialing Agreement, maintain tracking logs and monitor the status of managed care organization or other payer for compliance. Inform supervisor of non-compliance.
Establish and/or maintain electronic provider enrollment database(s) for assigned clinical practices. Support data integrity through analyzing and auditing demographic data. If deficiencies found, work with appropriate team members to update erroneous data. Routinely distribute provider enrollment database(s) to Stony Brook Medicine, including the physicians of the clinical specialties administered by the Clinical Practice Management Plan, Meeting House Lane Medical Practice, PC, the clinically integrated network and other interested constituents.
Respond to inquiries from insurance plans and internal team members.
Attend required meetings and participates in training programs as required; participates in a variety of professional activities.
Keep accurate communication records of contacts and verifying agencies within the department.
Develop and distribute notifications to internal team members.
Maintain current knowledge of NCQA, TJC, CMS and State Laws and regulations as they pertain to credentialing.
Other duties as assigned.
Required Qualifications: Associate's degree and at least three (3) years of direct experience in enrolling clinical health care providers either within a health care delivery organization or group of moderate or significant size or on behalf of a managed care organization or payer. Knowledge of NCQA, TJC, CMS and State Laws and regulations as they pertain to credentialing. Ability to work independently. Possess organizational skills. Excellent written and verbal communication skills, interpersonal skills, time management skills, critical thinking skills, problem solving skills, and project management skills.
Preferred Qualifications: Bachelor's degree and three (3) or more years of direct experience in enrolling clinical health care providers either within a health care delivery organization or group of moderate or significant size or on behalf of a managed care organization or payer. Exercise independent judgement in interpreting NCQA, TJC, CMS and State Laws and regulations as they pertain to credentialing. Experience with CACTUS or similar database software and Microsoft Office Suite.
This position will remain posted until filled or for 90 days max.
An initial review of all applicants will occur two weeks from the posting date. For full consideration, applications must be received before the initial review date (Which is within two weeks of the posting date). If within the initial review no candidate was selected to fill the position posted, additional applications will be considered for the posted position; however, the posting will close once a finalist is identified, and at minimal, two weeks after the initial posting date.
Please note, that if no candidate was identified and hired within 90 days from initial posting, the posting would close for review, and possibly reported at a later date.
Stony Brook Medicine is a smoke free environment. Smoking is strictly prohibited anywhere on campus, including parking lots and outdoor areas on the premises.
All Hospital positions are subject to changes in pass days and shifts as necessary. This position may require the wearing of respiratory protection, which may prohibit the wearing of facial hair.
The selected candidate must successfully clear a background investigation. Prior to start date, the selected candidate must meet the following requirements: Successfully complete pre-employment physical examination and obtain medical clearance from Stony Brook Medicine's Employee Health Services (The hiring department will be responsible for any fee incurred for examination), submit (3) written references, and provide a copy of any required New York State license(s)/certificate(s). Please be advised that failure to comply with any of the above requirements could result in a delayed start date and/or revocation of the employment offer.
About Stony Brook Medicine:
The best ideas in medicine start with the best people. At Stony Brook Medicine, our highest calling is to put the power of ideas to work in our patients' lives. Stony Brook Medicine integrates and elevates all of our health-related initiatives: education, research and patient care. Stony Brook Medicine is Long Island's premier academic medical center. With 603 beds, we serve as the region's only tertiary care center and Level 1 Trauma Center, and are home to the Stony Brook Heart Institute, Stony Brook Cancer Center, Stony Brook Children's Hospital, Stony Brook Neurosciences Institute, and Stony Brook Digestive Disorders Institute. We also encompass Suffolk County's only Level 4 Regional Perinatal Center, state-designated AIDS Center, state-designated Comprehensive Psychiatric Emergency Program, state-designated Burn Center, the Christopher Pendergast ALS Center of Excellence, and Kidney Transplant Center. It is home of the nation's first Pediatric Multiple Sclerosis Center.
Stony Brook University is an Affirmative Action/Equal Opportunity employer. We are committed to the creation of a diverse and inclusive campus climate. We encourage protected veterans, individuals with disabilities, women and minorities to apply.
This function/position has been designated as "essential." This means that when the Hospital is faced with an institutional emergency, employees in such positions may be required to remain at their work location or to report to work to protect, recover, and continue operations at Stony Brook Medicine, Stony Brook University Hospital and related facilities.
Pursuant to Executive Order 161, no State entity, as defined by the Executive Order, is permitted to ask, or mandate, in any form, that an applicant for employment provide his or her current compensation, or any prior compensation history, until such time as the applicant is extended a conditional offer of employment with compensation. If such information has been requested from you before such time, please contact the Governor's Office of Employee Relations at (518) 474-6988 or via email at firstname.lastname@example.org .
IF YOU NEED A DISABILITY-RELATED ACCOMMODATION, PLEASE CALL THE UNIVERSITY HUMAN RESOURCE SERVICES DEPARTMENT AT (631) 632-6161 OR THE UNIVERSITY HOSPITAL HUMAN RESOURCES DEPARTMENT AT (631) 444-4700. IN ACCORDANCE WITH THE TITLE II CRIME AWARENESS AND SECURITY ACT, A COPY OF OUR CRIME STATISTICS IS AVAILABLE UPON REQUEST BY CALLING (631) 632-6350. IT CAN ALSO BE VIEWED ON-LINE AT THE UNIVERSITY POLICE WEBSITE AT http://www.stonybrook.edu/police
Official Job Title: TH Instructional Support Associate
Job Field: Administrative & Professional (non-Clinical)
Primary Location: US-NY-Stony Brook
Department/Hiring Area: Medical Center Managed Care-Stony Brook University Hospital
Schedule: Full-time Shift: Day Shift Shift Hours: M-F 8:30 am - 5:00 pm Pass Days: Sat, Sun
Posting Start Date: Aug 7, 2019
Posting End Date: Nov 6, 2019, 4:59:00 AM
Salary: Commensurate with experience
Salary Grade: SL2
Internal Number: 1902811
About Stony Brook University
FROM ITS BEGINNINGS A HALF-CENTURY AGO, STONY BROOK UNIVERSITY HAS BEEN CHARACTERIZED by innovation, energy and progress, transforming the lives of people who earn degrees, work and make groundbreaking discoveries here. A dramatic trajectory of growth has turned what was once a small teacher preparation college into an internationally recognized research institution that is changing the world.