FRx- Senior Credentialing Coordinator

Fresenius Medical Care Nashville, TN
PURPOSE AND SCOPE:

The Sr. Credentialing Coordinator supports Fresenius Medical Care's core values and adheres to Fresenius Medical Care's Compliance Program, including following all regulatory and policy requirements. The incumbent utilizes expertise regarding federal and state regulations governing pharmacy certification and licensure to provide credentialing guidance and support to the related business. The Sr. Credentialing Coordinator assists in contracting and credentialing of pharmacy for participation in related health plan and networks (such as PBM).

PRINCIPAL DUTIES AND RESPONSIBILITIES:

* Provides information, support, and clarification to related staff and management regarding the regulatory requirements which pertain to continued participation in related health plan and networks (such as PBM).

* Completes state Boards of Pharmacy (BOP) licensure renewal applications for all 50 states. Updates BOP when provider information changes.

* Monitors and researches regulatory developments and program regulations pertaining to End Stage Renal Disease (ESRD) from the Centers of Medicare and Medicaid Services (CMS), the Centers for Disease Control (CDC), Food and Drug Administration (FDA), state Pharmacy Boards, and licensure regulations, identifying the impact of any changes or developments as they pertain to the business. Takes actions necessary to ensure all necessary parties are informed, providing clarification if needed and providing research findings to management.

* Provides support in resolving third party payor claim rejections for not-contracted.

* Maintains a complete and accurate database of claims for workflow management and financial impact reporting.

* Researches and seeks to resolve the claim rejection. Obtains clarification from related parties such as payor or PBM when necessary.

* Obtains and prepares contract requests when the business is found to be out-of-network with the health plan.

* Provides Manager of Payer Relations with all new provider network contract opportunities.

* Completes Medicaid, Medicare, and third party contract renewals, to ensure provider statuses are kept in good standing. Ensures timeliness, accuracy and efficiency in the completion of all pertinent credentialing and regulatory applications.

* Responds to any contract renewal correspondence on a daily basis. Ensures that timelines are met for renewals and initial credentialing as communicated with related health plans and networks (such as PBM).

* Applies for and completes health plan provider and network agreements, when needed.

* Responsible for preparation and submission of applications for Medicare certification and state licensure.

* Assists Manager of Payer Relations, AR Manager, and Accounting Manager with resolving contract reimbursement issues. Records and tracks contract requirements; quantifies and justifies reimbursements.

* Responds to and monitors third party payor audits of credentialing documentation and pharmacy claims. Maintains a database of all pharmacy audits and reports on their financial impact.

* Maintains and updates an organized credentialing and contracting filing database system.

* Organizes data to support the credentialing process and reporting needs.

* Maintains a complete and accurate database of historical applications.

* Monitors expiring/expired licenses and certificates.

* Purges files of expired and unnecessary documents and reports.

* Continually audits and reviews the credentialing and contracting process. Identifies and recommends techniques to improve workflows on an ongoing basis and to ensure compliance.

* Maintains a summary report of Medicaid license information and distributes to primary contacts, such as management and executive team.

* Reviews and researches various Medicaid limitations related to being an out of state provider for most states. Identifies options to eliminate/reduce these limitations.

* Contributes to the development and management of Compliance Self-Monitoring initiatives. Ensures that the business is meeting CMS standards of compliance in regards to credentialing. Collects data and obtains necessary approvals.

* Works with and reports to specific payers or agencies to maintain licensure.

* Requests and/or develops reports required by the payer, acting as a liaison with internal departments to ensure required information is maintained and up to date.

* Participates in Department's initiatives to support the implementation of corporate quality goals and action plans.

* Coordinates and assists with related accreditation efforts, when needed.

* Completes special projects related to maintaining provider networks and obtaining the information that may be required by the network or agency.

* May be required to create training tools for related staff, as needed, relating to provider statuses and reimbursement.

* Escalates issues to supervisor/manager for resolution, as deemed necessary.

* Builds productive working relationships.

Additional responsibilities may include focus on one or more departments or locations. See applicable addendum for department or location specific functions.

PHYSICAL DEMANDS AND WORKING CONDITIONS:

The physical demands and work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

EDUCATION:

Bachelor's Degree required with an emphasis in Business or Healthcare, or 5 years AR in healthcare, managed care contracting and/or credentialing experience or related Regulatory Agency experience in lieu of Bachelor's Degree.

EXPERIENCE AND REQUIRED SKILLS:

* 2 – 4 years' related experience.

* Strong organizational skills, with the ability to administer multiple tasks and prioritize.

* Excellent communication skills, written and oral, with the ability to communicate to all levels of personnel.

* Excellent customer service skills.

* Strong personal computer skills.

* Excellent organizational and analytical skills.

EO/AA Employer: Minorities/Females/Veterans/Disability/Sexual Orientation/Gender Identity