GENERAL SUMMARY:

Under general supervision, performs provider enrollment and compliance functions

within a Clinically Integrated Network (Network). Key duties include data management,

ensuring providers meet standards and regulations, processing Network credentialing

applications, maintaining relationships between payors, clinics, and providers, and

verifying compliance with contractual obligations. The role performs further credentialing

functions including resolving claims issues, assisting with onboarding new practices,

and conducting audits to ensure compliance. Responsible for creating communication

materials, maintaining up-to-date payor information, and providing patient support for

Medicaid redetermination and enrollment.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

1. Ensures providers are enrolled in the Network according to current standards and

regulations and maintains stringent compliance with payors.

2. Facilitates preparation for the Network Credentialing Committee, reviewing files for

accuracy and completion. Works with the Committee Chair to perform the

administrative review process and attain approval sign-off.

3. Responsible for meeting any contractual obligations outlined within all delegated

credentialing agreements held by the Network.

4. Serves as the point of contact for Network practices to address claims issues with

Network payors by troubleshooting on behalf of the practice and working with the

payor to resolve.

5. Provides enrollment assistance/support to Network provider members for nondelegated health plans as needed.

6. Supports new practice onboarding by providing support pertaining to credentialing,

execution of participation agreements, health plan enrollment, fee schedules, and

ensure smooth transition of support to Network practice transformation team.

7. Performs data entry, collection, and analysis to complete tasks supporting provider

primary source verifications and enrollment processes.

8. Responsible for completing various audit activities to ensure contractual compliance

and satisfying NCQA standards. Audit activities include annual audits which are

initiated by delegated payors, regular auditing of primary source verifications (PSV),

and conducting annual audits of sub-delegate groups to the Network, such as the

Henry Ford Health Central Verification Office.

9. Ensures Network practice compliance and contractual obligations through

comprehensive and manual validation of information (i.e., confirmation of practice

hours). Performs tasks to support accurate records and roster management

including:

a. Network provider membership profiles within Network’s data management tool.

b. Updates external provider alignment tools used to align physicians to a particular

group for purposes of their quality rewards program.

c. Maintains accurate record of specialist referral information, provider panel status

by product line, and Network’s criteria for incentive eligibility.

d. Supports Network patient alignment including but not limited to member transfer

submissions and resolution tracking.

e. Responsible for accurate and prompt submission of the Network provider roster

to each payor using payor-specific formatting. Additional ad-hoc requests require

creation of provider rosters, using variety of data platforms, for multiple usecases.

f. Maintains the Network provider roster for the Accountable Care Organization

(ACO) contract including all provider additions, terminations, or changes to the

ACO contract.

g. Maintains current payor information, including fee schedules and policies, within

the Network's SharePoint website.

h. Through ongoing partnerships and collaboration with non-delegated health plans,

ensures all appropriate providers are accurately aligned to Network.

10.Performs outreach to patients due for Medicaid redetermination, provides education

to patients on process, answers questions, assists with online forms, and provides

enrollment support.

11.Follows the procedures defined by Network’s patient compliant policy including

reviewing patient concerns with Network administrative leadership and Network

medical directors.

12.Supports the Network communications and education through creating a monthly

payor newsletter capturing updates from Network contracted health plans including

coding, billing, prior authorizations, upcoming webinars, operations, and provides

CPT coding and billing education to Network members.

13.Performs ongoing evaluation, maintenance, and execution of the Network

participation agreements. Maintains all policies and procedures related to Network

provider affairs and delegated credentialing.

14.Additional responsibilities including, but not limited to:

a. Maintenance of the Network Behavioral Health Provider Directory.

b. Attending the Network Credentialing Committee as requested by leadership.

c. Submission of Blue Care Network's Medical Care Group affiliation form for

Network independent providers.

d. Payor outreach as needed on behalf of providers.

EDUCATION/EXPERIENCE REQUIRED:

• High school diploma. Associate degree preferred.

• Two (2) years of provider enrollment, provider billing, or credentialing experience.

• Demonstrated knowledge of all aspects of the insurance provider enrollment

process.

• Ability to work independently, in a demanding environment, managing deadlines and

competing priorities without compromising quality or accuracy.

• Meticulous, highly organized with strong business acumen, quantitative and

analytical skills.

• Excellent verbal and written communication skills.

• Comfortable and competent interpreting information and making decisions.

• Demonstrated ability to interact professionally with all levels of business and clinical

organizations.

• Proficient in Microsoft suite of tools including Outlook, Word, and Excel.

• Proficiency in relevant applications including EPIC, Morrisey, and/or MDStaff

preferred.

CERTIFICATIONS/LICENSURES REQUIRED:

Certified Professional Coder (CPC) preferred.

Must meet or exceed core customer service responsibilities, standards and behaviors as

outlined in the Henry Ford Health Customer Service Policy and summarized below:

 Communication  Ownership

 Understanding  Motivation

 Sensitivity  Excellence

 Teamwork  Respect

Must practice the customer skills as provided through on-going training and in-services.

Must possess the following personal qualities:

 Be self-directed.

 Be flexible and committed to the team concept.

 Demonstrate teamwork, initiative, and willingness to learn.

Additional Information

• Organization: Corporate Services

• Department: HF CIN

• Shift: Day Job

• Union Code: Not Applicable

  Additional Details

  This posting represents the major duties, responsibilities, and authorities of this job, and is not intended to be a complete list of all tasks and functions. It should be understood, therefore, that incumbents may be asked to perform job-related duties beyond those explicitly described above.

Overview

Partnering with nearly 2 million people on their health journey, Henry Ford Health provides a full continuum of services at 250 care locations throughout southeast and south central Michigan. With 33,000 valued team members, Henry Ford is also among Michigan’s largest and most diverse employers. Our superior care and discoveries are powered by nearly 6,000 physicians, researchers and advanced practice providers. Learn more athenryford.com.

Benefits

Whether it's offering a new medical option, helping you make healthier lifestyle choices or making the employee enrollment selection experience easier, it's all about choice. Henry Ford Health has a new approach for its employee benefits program - My Choice Rewards. My Choice Rewards is a program as diverse as the people it serves. There are dozens of options for all of our employees including compensation, benefits, work/life balance and learning - options that enhance your career and add value to your personal life. As an employee you are provided access to Retirement Programs, an Employee Assistance Program (Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness, and a whole host of other benefits and services. Employee's classified as contingent status are not eligible for benefits.

Equal Employment Opportunity/Affirmative Action Employer

Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health is committed to the hiring, advancement and fair treatment of all individuals without regard to race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height, weight, marital status, family status, gender identity, sexual orientation, and genetic information, or any other protected status in accordance with applicable federal and state laws.