Credentialing and Utilization Review Specialist - Private Insurance
hace 5 días
Tulsa
Job Description CREOKS Health Services is establishing a mobile primary care clinic and expanding primary care services under the Oklahoma State Department of Health Rural Health Transformation Program (Rural Regional Reorientation). This position carries two related responsibilities on the payer side of those services. First, it enrolls and maintains CREOKS providers and service locations with commercial and private insurance payers so that services are billable. Second, it manages prior authorization, concurrent review and medical necessity denial activity so that authorized services are paid. The two functions are deliberately combined. Credentialing is heaviest at program start-up, when providers and the mobile clinic must be enrolled before any claim can be submitted. Utilization review activity is minimal at start-up and grows as patient volume grows. One person can carry both across the life of the program. This position is funded through the RRR subaward. A central purpose of the role is to build CREOKS’ internal capacity: the contractor is expected to document the workflow and train CREOKS staff so the agency can carry the function independently at the conclusion of the grant period. Duties & Responsibilities: • Complete and submit initial credentialing and re-credentialing applications for CREOKS providers to commercial and private insurance payers., • Create and maintain CAQH profiles for all participating providers, including attestation on the required cycle., • Obtain and maintain individual (Type 1) and organizational (Type 2) National Provider Identifiers, and confirm that taxonomy codes correspond to the services billed., • Track expiration dates for licenses, DEA registrations, board certifications, malpractice coverage, and other credentialing documents, and obtain renewals before any lapse., • Maintain the provider roster with each contracted payer, including additions, terminations, and changes in practice location., • Initiate and track payer enrollment for new service locations, including registration of the mobile medical clinic as an approved service location with each payer., • Follow up with payers on pending applications, escalate delays, and communicate confirmed effective dates to billing and clinic leadership., • Perform primary source verification of credentials in accordance with CREOKS policy and CARF standards., • Coordinate with the Billing Specialist so that claims are submitted only for providers and service locations with active payer effective dates., • UTILIZATION REVIEW — Obtain prior authorizations from commercial and private payers for primary care and behavioral health services, and confirm authorized service units, effective dates and expiration dates before services are delivered., • Track all active authorizations and initiate concurrent or continued stay review in advance of expiration, so that no authorized episode lapses while a patient remains in service., • Compile and submit the clinical documentation supporting medical necessity, as prepared and attested to by the treating clinician, in the format and within the timeframe each payer requires., • Monitor claim denials attributable to authorization or medical necessity, identify the cause, and coordinate appeals — including assembling the record, meeting payer appeal deadlines, and scheduling peer-to-peer review between the payer and the CREOKS clinician., • Maintain a log of authorization requests, approvals, denials, appeals and outcomes sufficient to show the disposition of every request., • Report authorization turnaround, denial reasons and appeal outcomes to clinical and business office leadership, and flag payer patterns that affect access or revenue., • Serve as the CREOKS point of contact with payer utilization management departments., • Document the authorization and utilization review workflow in step-by-step form, payer by payer, alongside the credentialing workflow, so that CREOKS staff can operate both processes independently at the conclusion of the grant period., • Document the credentialing and payer enrollment workflow in step-by-step form, including payer-specific detail, so that CREOKS staff can operate the process independently at the conclusion of the grant period., • Train designated CREOKS staff on the documented workflow and verify competency before the contract ends., • Maintain credentialing files and provider information in accordance with HIPAA, CARF, and CREOKS policy., • Read and be knowledgeable of all current CREOKS policies and procedures., • Responsible for understanding and following all administrative, clinical, and programmatic policies and procedures of the agency., • All other duties as assigned. Qualifications / Competencies Required: • High school diploma or equivalent required; associate or bachelor’s degree preferred., • Minimum of two (2) years of provider credentialing and payer enrollment experience, including direct experience with commercial and private payers., • Working knowledge of CAQH, NPPES, PECOS, and commercial payer enrollment portals., • Certified Provider Credentialing Specialist (CPCS) through the National Association Medical Staff Services preferred., • Familiarity with CARF, Joint Commission, or NCQA credentialing standards preferred., • Experience credentialing advanced practice registered nurses, physicians, and licensed behavioral health professionals preferred., • Minimum of one (1) year of experience obtaining prior authorizations, managing concurrent review, or working medical necessity denials and appeals with commercial payers; experience in a behavioral health or integrated primary care setting preferred., • Working knowledge of payer medical necessity criteria and utilization management portals. Familiarity with ASAM criteria, LOCUS or CALOCUS preferred., • Working knowledge of CPT, HCPCS and ICD-10 sufficient to confirm that an authorization matches the service delivered and billed., • Understanding of payer appeal rights and deadlines, and the ability to assemble a complete appeal record., • Demonstrated ability to track numerous concurrent deadlines and maintain accurate, auditable records., • Demonstrated ability to document a process clearly and transfer it to other staff., • Working knowledge of HIPAA and confidentiality requirements., • Strong attention to detail and the ability to work independently with limited supervision. Travel and Other Special Conditions: • This is primarily an administrative position. Occasional travel to CREOKS clinic locations may be required for staff training and document collection., • Remote or hybrid work arrangements may be available subject to CREOKS policy., • Travel reimbursed per CREOKS policy.\nCompany Description CREOKS Health Services is a non-profit organization providing comprehensive health, wellness, and social services. Our behavioral health division offers more than 40 years of quality services and program that benefit adult, adolescents, and children. We currently have 33 locations across Eastern & Southeastern Oklahoma. CREOKS’ reputation has allowed us to work with local agencies, schools, and civic organizations. Whether you’re new to the field or a seasoned professional, joining CREOKS gives you the opportunity to affect meaningful change in people’s lives. It also means being a part of an accredited and recognized nonprofit who invests in your future. CREOKS offers a collaborative, positive work environment, free Continuing Education workshops, the NHSC Loan Repayment Program, competitive pay and a comprehensive benefits package. CREOKS Health Services is a non-profit organization providing comprehensive health, wellness, and social services. Our behavioral health division offers more than 40 years of quality services and program that benefit adult, adolescents, and children. We currently have 33 locations across Eastern & Southeastern Oklahoma. CREOKS’ reputation has allowed us to work with local agencies, schools, and civic organizations.\r\n\r\nWhether you’re new to the field or a seasoned professional, joining CREOKS gives you the opportunity to affect meaningful change in people’s lives. It also means being a part of an accredited and recognized nonprofit who invests in your future. CREOKS offers a collaborative, positive work environment, free Continuing Education workshops, the NHSC Loan Repayment Program, competitive pay and a comprehensive benefits package.
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