Under supervision, initiates the enrollment and credentialing process for MassHealth provider applications and complies and processes data in compliance with program requirements. This position ensures thorough and timely verification of all provider credentials and application materials. This will include, but not be limited to, responsibility for credentialing new and established health care providers, and the maintenance of information including; primary source verification, provider follow-up, data collection, data entry, and document file review and provider update requests. PEC specialists are often the first point of contact with an applicant and can impact a provider's impress of MassHealth and influence their interest to join or remain in the network.
. Performs credentialing and re-validation activities for prospective and current MassHealth providers according to established guidelines. Duties include; reviewing provider applications, applying policy and criteria based on provide type, performing source verifications and processing provider files. Ensures provider compliance in regards to licensing and sanction information with all accrediting organizations and regulatory agencies including; but not limited to BORIM, DPL, LEIE, CHIP, MCSIS, NPPES and EPLS.
2. Maintain provider updates as requested, verifying data and entering information into NEWMMIS. Completes all documentation and data entry in a timely and accurate fashion.
3. Follows regulation timeframes and procedural guidelines for processing applications, updates and disenrollment activities according to company and contract standards.
4. Responds to all provider enrollment related inquiries and requests in a timely and thorough fashion. Maintains professional interactions with providers, persistently following up on missing enrollment information and required documentation to complete file.
5. Communicates to providers any regulations and certification changes that affect file maintenance or membership, obtaining necessary documentation from providers for processing.
6. Communicates provider problems, inquiries or issues that cannot be resolved independently through the appropriate channels for resolution.
7. Ability to make determinations regarding applicable provider files to be elevated for additional review and/or escalation. Collects all pertinent documentation that supports escalation actions for Supervisor review.
Working hours: 8 AM - 5 PM
1. Ability to read and interpret written information from a variety of sources
2. Ability to work well under pressure in a fast-paced, deadline orientated work environment.
3. Ability to manage multiple priorities.
4. Ability to communicate clearly and concisely.
5. Accuracy and attention to detail is a MUST.
6. Must have excellent interpersonal and written communication skills.
7. Strong customer service orientation. Ability to establish and maintain relationships, building trust and respect by consistently meeting and exceeding expectations.
Associates degree or Bachelor's
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