Payer Credentialing Specialist

Job Description

Job Description

Salary : $27-$33 Hourly / DOE

About AmeriPharma

AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis.

We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.

AmeriPharma’s Benefits

• Full benefits package including medical, dental, vision, life that fits your lifestyle and goals
• Great pay and general compensation structures
• Employee assistance program to assist with mental health, legal questions, financial counseling etc.
• Comprehensive PTO and sick leave options
• 401k program
• Plenty of opportunities for growth and advancement
• Company sponsored outings and team-building events
• Casual Fridays

Job Summary

As a Payer Credentialing Specialist at AmeriPharma, you will be responsible for all aspects of credentialing and re-credentialing as it relates to

provider enrollment with payors, and other entities. This position ensures all providers are appropriately credentialed, which includes the responsibility of maintaining current information on file and within the credentialing database.

The Specialist is responsible for timely provider updates and directory accuracy with all health plans.

Schedule Details

• In-Person (Orange, CA.)
• Monday-Friday 8 : 00am-4 : 30pm

Duties and Responsibilities

Completion and submission of Company credentialing and re-credentialing applications and documentation to

acquire provider enrollment within the United States

Maintenance of profiles and internal credentialing database and ensure up-to-date information is obtained at

all times

Responsible for monitoring and managing credentialing / re-credentialing requirements and to ensure the

collection and submission of all required renewal certifications are on file within the required time frame

• Provide consistent and timely follow-up on all outstanding credentialing / re-credentialing applications
• Provide support to Company’s Revenue Cycle staff, health plan contacts and company departments as

necessary

• Timely updates to provider directory information on several platforms to comply with payors provider manuals
• Supports and actively participates in process improvement initiatives
• Track and coordinates contract status amongst Health and Prescription plans
• Provides contract status to Compliance and / or management and coordinates any additional communication

with external contracting contacts to finalize agreements

Upon contract / agreement receipt from client / payor will assist in tracking the execution of such contract by

ensuring all signatures are in place. This includes follow-up to ensure counter signatures are returned from

external parties

Ensures all payors contracts / agreements and related documents are stored and maintained properly into the

system

• Ensures proper plan / Medical group contract’s contact information is inputted into contract systems
• Assists management with credentialing questions and / or requests coming from external or internal parties
• Ensures that partnering tools and materials content including but not limited to LOI’s, Fee Schedules, portfolio

presentations are up to date

• Initiate research and outreach of potential partners provider enrollment inquiries and initial letter of interest outreach
• Initiate research and outreach of potential out-of-state commercial and government payors
• Assists in preparing fee schedule proposals and negotiations
• Communicate receipt and processing of all payor contracts, credentialing, reimbursement updates and

correspondence

Assist in reviewing contract compliance and adherence to DMHC, DHS, CMS and other regulatory agencies as

required by payors

• Works collaboratively with management to ensure department goals and requirements are being met
• Conducts review of profitability periodically or as needed
• Ensures compliance with all payer rules and regulations
• Ensures compliance with all company policies and procedures
• Assists with other duties to support the process and the company’s core values

Required Qualifications

• Payors contracting and enrollment experience
• Advanced knowledge of health care delivery systems, Managed Care Organizations as well as Medicaid / Medicare and related state programs
• Experience with PAVE (Provider Application and validation for Enrollment) PECOS (Provider Enrollment Chain and Ownership System)
• Ability to understand multiple levels of prescription and medical benefits, and industry reimbursement methodologies
• Proficient with Microsoft Office Suite or related software

Education and Experience Requirements

• Bachelor’s Degree in Healthcare Administration, Business Administration, or equivalent.
• At least two years recent enrollment / credentialing experience in healthcare settings.

Required Skills

• Verbal and written communication skills
• Ability to interpret, adapt and apply guidelines and procedures
• Ability to establish and maintain effective working relationships with payors, staff and coworkers
• Demonstrates accuracy, strong analytical and problem-solving skills
• Looks for ways to improve and promote quality and monitors own work to ensure quality is met
• Maintain confidentiality
• Work independently, prioritize work activities and use time efficiently
• Excellent interpersonal and customer service skills
• Excellent organizational skills and attention to detail
• Excellent time management skills with a proven ability to meet deadlines
• Ability to prioritize tasks and to delegate them when appropriate
• Ability to function well in a high-paced and at times stressful environment

AmeriPharma’s Mission Statement

Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients.

It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!

Physical Requirements

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is continuously required to sit and talk or hear.

The employee is occasionally required to stand; walk; use hands to finger, handle, or feel objects, tools, or controls; reach with hands and arms;

and stoop, kneel, crouch or crawl. The employee must regularly lift and / or move up to 20 pounds and occasionally lift / or move up to 30 pounds.

Specific vision abilities required by this job include close vision, peripheral vision, depth perception and the ability to adjust focus.

EEO Statement

The above statements are intended to describe the work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required.

The duties and responsibilities of this position are subject to change and other duties may be assigned or removed at any time.

AmeriPharma values diversity in its workforce and is proud to be an AAP / EEO employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, sexual orientation, gender identity, national origin, age, protected veteran status, or based on disability or any other legally protected class.