Southeastern Arizona Behavioral Health Services, Inc.
Credentialing Specialist
Reports To: Sr. Business Analyst Salary Range: 18 FLSA: Non-Exempt
Annual Salary Range: $21,275-$33,004
Primary Function: Maintain, assist and complete applications packets for direct service staff in obtaining credentialing status with commercial insurance and special contract panels to ensure compliance with licensing and service delivery.
Minimum Qualification: Combination of education and experience equivalent to three years office experience with increasing responsibility in medical or behavioral health setting and one (1) year experience in working with medical insurance billing and/or contract compliance one (1) year experience in customer service. Must have demonstrated ability in MS Office.
Competencies:
• Knowledge in utilization of personal computer
• Ability to communicate well verbally and in writing
• Ability to type correspondence and reports and maintain files.
• Ability to maintain organization of varied materials and apply complex direction quickly and correctly.
• Ability to disseminate credentialing information to ensure proper billing procedures are implemented and followed.
• Ability to prepare and maintain accurate records.
• Ability to research credentialing requirements.
• Ability to complete, review, maintains and assists direct service staff with credentialing packets and resolve discrepancies in a timely manner.
• Knowledge of commercial insurance and administration.
• Knowledge of the principles and practices of managed care in the delivery of behavioral health services.
• Ability to perform analysis of moderate complexity.
• Ability to communicate ideas of moderate complexity in writing.
• Familiarity with behavioral health licensure requirements, member rights, behavioral health or medical member processing, billing, funding information or other behavioral health issues.
• Knowledge of office software, including MSWord, Excel or Access.
• Ability to maintain confidentiality of all client matters and handle organization confidential matters with discretion.
Tasks:
• Develop, distribute and maintain all direct service credentialing packets, including both commercial insurance and specialty contracts.
• Develop various forms; reports with regard to staff credentialing.
• Audit credentialing packets prior to PSO/MSO for presentation and acquiring appropriate signatures
• Attend monthly PSO/MSO meetings, present approved and upcoming expiration of direct service staff credentialing status with supporting documentation, transcribe meeting minutes and disseminate meeting minutes to attendees
• Disseminate approved credentialing packets to CPSA
• Complete responsibility for development maintenance and distribution of credentialing packets, including responsibility for tracking licensure and insurance renewals and working with other software programs to correlate information
• Responsible to work with Human Resources to ensure that all direct service staff meet minimum credentialing requirements of both the commercial insurance and/or contract agency.
• Work closely with Contracts, Billing, HR, MIS and UM to assure that all requirements are met with regard to direct service staff, so that services may be encountered.
• On a monthly basis notify (Pima Health Systems, Cochise Health Systems (ALTCS), Carondelet, Sierra Vista Hospital) of terminated medical staff
• On a monthly basis notify commercial insurance and contracts of termed employees for credentialing
• Maintain adult/children prescriber roster with accuracy in addition to their hours by site
• Maintain roster for masters level an above with accuracy by site
• Responsible to data entry contracted staff required information into CMHC once staff ID has become activated
• Performs other duties as assigned.
Accountability: Reports to and is supervised directly by the Sr. Business Analyst. Employee is also accountable for understanding and complying with policies and procedures, terms of certification, licensure and accreditation standards.
Independent Judgment/Autonomy: Works under functional directions and clearly defined objectives,, which are reviewed on a broader frequency such as monthly, quarterly or annually.
Supervisory Responsibility: This position holds no supervisory responsibility, responsible for own work only
Behavioral Skills Required:
• Coping: Able to maintain a mature, problem-solving attitude while dealing with interpersonal conflict, hazardous conditions, personal rejection, hostility, or time demands.
• Tolerance of Ambiguity: Able to withhold actions or speech in the absence of important information; deal with unresolved situations, frequent change, delays, or unexpected events.
• Decisiveness: Able to make decisions on available information and take action; make commitments and not change decisions when challenged; deal with emergencies as necessary.
• Spoken Communications: Able to clearly present information through the spoken word; influence or persuade others through oral presentations in positive or negative circumstances; listen well.
• Assertiveness: Able to maturely express one's opinions and feelings in spite of disagreement; accurately communicate to others regardless of their status or position.
• Energizing: Able to create positive energy (motivation) in both individuals and groups.
• Compliance and Direction: Able to relate to routine operations in a manner that is consistent with existing solutions to problems; to conform to established policies and procedure; log work activities.
• Analytical Problem Solving: Able to use a systematic approach in solving problems through analysis of problem and evaluation of alternative solutions; use logic, mathematics, or other problem-solving tools in data analysis or in generating solutions.
• Goal Setting: Able to define realistic, specific goals and objectives; to prioritize objectives.
• Written Communication: Able to write clearly and effectively present ideas and to document activities; to read and interpret written information.
• Commitment to Task: Able to start and persist with specific courses of action while exhibiting high motivation and a sense of urgency; willing to commit to long hours of work and make personal sacrifice in order to reach goals.
• Interaction: Able to communicate with others in a warm and helpful manner while simultaneously building credibility and rapport.
• Creativity: Able to develop unique and novel solutions to problems; use intuition and a new way of thinking to give birth to new ideas; to present information in an attention-getting and interesting manner.
• Versatility: Able to modify one's own behavioral style to respond to the needs of others while maintaining one's own objectives and sense of dignity.
• Reading the System: Able to recognize and use information about organizational climate and key individuals to accomplish legitimate organizational goals; be aware of the importance of timing, politics, and group commitments to goals and objectives.
• Team Building: Able to work with people in such a manner as to aid in building high morale and group commitments to goals and objectives.
• Decision Making and Problem Solving: Able to take action in solving problems while exhibiting judgment and a realistic understanding of issues; able to reason; even when dealing with emotional topics.
• Leadership: Able to influence the actions and opinions of others in a desired direction; to exhibit judgment in leading others to worthwhile objectives.
• Organizational Awareness/Resourcefulness: Demonstrates a comprehensive sensitivity to power and influence relationships in own organization. Able to identify key people who influence particular decisions.
• Adaptability/Flexibility: Adapts easily to change, sees the merits of differing positions, and adapts own positions and strategies in response to new information or changes in a situation.
• Personal Growth/Attention to Development: Desires to improve and develop self; sets own development challenges and volunteers to learn.
• Reliability: Instills confidence in others due to proven consistent and positive outcomes.
• Initiative: Evaluates, selects, and acts on various methods and strategies for solving problems and meeting objectives before being directed or forced by events; self-directed rather than passively complying with instructions or work orders.
• Teamwork and Collaboration: Able to develop cooperation and collaborative work efforts toward solutions which generally benefit all involved parties.
Cognitive Requirements: Job requires solid verbal/written communication and the ability to: 1) read, comprehend and interpret procedures and moderately complex documents; 2) analyze and resolve difficult human, technical or administrative problems; and 3) interact with senior internal and external personnel on significant matters which often require consideration of activity across organizational functions.
Continuous Education: Employees will be expected to participate in continuous learning,
competency building and maintenance of competency skills. New employees, specifically, who provide direct services, require forty-eight hours of in-service training the first year and twenty-four hours per year thereafter.
Physical Requirements:
• Use a Personal Computer of telephone over five hours a day
• Frequent long, irregular hours
• Frequent and/or prolonged travel
• Occasional reaching, bending, stooping, kneeling or crouching
• Infrequent moderate physical effort (lift/carry up to 25 pounds)
Performance Metrics:
• Tracking contracts when they are mailed to other agencies and tracking the turnaround time so that they can be executed.
• Keep current all OBHL Licensure and Certificate of Insurances.
• Development of third party, expense/revenue database.
• Saving the company money by negotiating matrix rates.
Mentor Criteria:
• A mentor will be personable and patient, with good, open communication skills. A mentor will be knowledgeable in SEABHS systems and procedures. A mentor will be a self motivated individual with the ability to positively support their peers.
Mentor Scope of Responsibility:
• A mentor provides side by side, hands on shadowing, with consistent and constructive feedback. The mentor oversees accuracy, as well as verbal and visual skills with on-going communication to the direct supervisor.
Working Conditions:
• Office working conditions
Employee's Name (Printed) Supervisor's Name (Printed)
Employee's Signature Date Supervisor's Signature Date
Revised 11/15/09
