Managed Care Contracting and Credentialing Specialist
Overseeing proposal plans, adjustments, biddings, preparing, revising and administration of contracts that involve the purchase of sale of goods and services. Collecting relevant and critical data to determine applicant's eligibility to contract with the organization by creating relationship with vendors. Managed the flow of information between the managed care payers and contracted MSO facilities. Record and tracked contract statistics for future reporting while performing verification of applications, data entry, and reporting. Ensure all expiable are reviewed, obtained and managed on a monthly basis according to rules and policies. Maintain the confidentiality of all business, work and contracting information to ensure contract execution in accordance with company policy.
- Prepare contract briefs and revisions, summarizing contractual requirements and budgets. Tracking authorizations and correspondence with industry trends and produces member supply reports. Processed and communicated with practitioner additions, deletions, and/or changes to all contracted vendors. Negotiate pricing, terms and conditions, mutually agreeable solutions to identify compliance issue, work proactively and effectively to overcome and prevent internal and external compliance problems from inception to completion. Conducts market competitive analysis, promotes best practices across membership, development of contract maximization strategies. Research complete and submit credentialing, re-credentialing and change of information applications for Medicare and other insurances. Review, maintain and update department contract and Medicare files, and application databases to keep information current and accurate. Analyze and mitigate risk.
- Prepare and disseminate information to appropriate employees regarding contract status, facilitate contractor meetings. Ensure that contractor is in compliance with legal requirements, owner specifications and government regulations. Gathered and conducted verification of provider credentials for internal & external communications regarding all payer and vendors. Researched, completed and maintained compliance with facility and delegated payers through audit processes and procedures. Responsible for maintaining contracting system upgrades/enhancements and preparing for managed care contracted MSO facility audits. Prepared, payer relations & facility delegate at internal and external meetings and documents to be reviewed for contract approval and execution by senior management. Monthly reporting to Revenue Cycle Operations of Contractual Status. Maintain detailed and organized files.
- Perform closing activities as needed. Track payments and deadlines to sales department by proving support to resolve open accounts receivables, credit approval, deductions and other outstanding receivable issues. Assisted/support customer service policies and procedures, to improve customer service and provide timely resolutions by requesting for proposal and quotation. Provide creative ways to refine customer history reports, DSO summaries by customer, product and region by analyzing business metrics data to Director of A/R. Obtained updated fee schedules for proposals and payment methodology from various contracts and contractual documents. Prepare contract change notices, monitor contractor performance, including the reporting and status of contractor and owner deliverables, while maintaining an audit file for each contract.