Position Overview
The Revenue Cycle Contract Credentialing Specialist will facilitate contract implementation by being proactive and reactive, with internal and external parties to ensure the public and private payer contract paperwork and credentialing is in alignment with corporate goals, contracts, and/or regulations. This role is responsible for facilitating and managing the credentialing of contracts for both government and commercial contracts, working closely with market access and the legal contracting teams in developing and maintaining agreements that provide medical providers and patients with access to our assays while aligning with Exact Sciences’ goals and objectives.
This position is field based.
Essential Duties
Include, but are not limited to, the following:
- Prepare and maintain credentialing files and reports for all payors and government entities.
- Expand both government and commercial payor profiles to include all lines of business units due to mergers and acquisitions; complete updates required by contracts for credentialing, disclosure, and demographic information.
- Process and file applications with third party payors according to each payor’s individual requirements and addresses discrepancies, as requested, by payors.
- Conduct all follow up steps until payor approval, completion, and acceptance is obtained.
- Update NPI records according to provider specifications.
- Enroll provider in Medicare/Medicaid as prescribed by each program's requirements.
- Track licensure, accreditation, and insurance certificate expiration dates to ensure timely processing to be compliant with mandates for contractual agreements with state and federal regulations with payors.
- Complete requests for re-credentialing for payors, commercial, and government entities.
- Accept and process all requests from payers for credentialing information, updates, and new contracts and assays.
- Answer questions, inquiries, and process requests from all internal and external stakeholders related to credentialing information.
- Enroll all business units in Medicare/Medicaid programs.
- Address enrollment deficiencies and payor issues regarding commercial and government entities.
- Assist with electronic funds transfer (EFT) and electronic data interchange (EDI) enrollment, tracking, and filing.
- Serve as liaison between parent subsidiaries, third party billing agents, payors, commercial, Government entities, and all stakeholders to ensure revenue/reimbursement pull through.
- Maintain historical data and files.
- Interface with multiple departments to provide updates and stay abreast of current initiatives that could affect credentialing and enrollment.
- Monitor incoming emails for Odxclaimsupport, Payor Credentialing, GovTeam, ManagedCareContracts, Contact ManagedCare, and CommercialOpsFax.
- Effective communication skills, both written and oral, across internal and external stakeholders.
- Promote an open, collaborative environment built on trust to foster positive teamwork.
- Apply strong attention to detail, organizational, and analytical skills.
- Ability to prioritize and manage several projects at once and drive to results with a high emphasis on quality.
- Ability to influence without authority.
- Ability to identify and implement enhancement opportunities.
- Ability to integrate and apply feedback in a professional manner.
- Uphold company mission and values through accountability, innovation, integrity, quality, and teamwork.
- Support and comply with the company’s Quality Management System policies and procedures.
- Regular and reliable attendance.
- Ability to act with an inclusion mindset and model these behaviors for the organization.
- Ability to work on a mobile device, tablet, or in front of a computer screen and/or perform typing for approximately 90% of a typical working day.
- Ability to work on a computer and phone simultaneously.
Minimum Qualifications
- Associates degree in healthcare administration, public health, business administration, or related field; or high school degree/general education diploma and 2 years of relevant experience in lieu of Associates degree.
- 1+ years of contracting experience within the healthcare industry.
- Demonstrated knowledge of public and private Managed Care payers and reimbursement processes.
- Demonstrated understanding of market-related issues, contract development, negotiation, and pull through, as well as the legal and regulatory implications associated with private and government payer contracting.
- Basic knowledge of Microsoft Office; including Word, Excel, Access, Outlook, and PowerPoint.
- Demonstrated ability to perform the Essential Duties of the position with or without accommodation.
- Authorization to work in the United States without sponsorship.
Preferred Qualifications
- 3+ years of contracting experience within the healthcare industry.
