Registered Nurse (RN) - PCU - Progressive Care Unit
Children's Medical Center Dallas
Dallas, TX

Job Title & Specialty Area: Credentialing Specialist Managed Care

Department: Managed Care

Location: Dallas, TX

Shift: Monday - Friday

Job Type: Remote in Texas only

Why Children’s Health?
At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:

The Managed Care Credentialing Coordinator is responsible for performing credentials verification for Children's Health employed and contracted practitioners and those who join 162.001(b) provider groups to ensure compliance with standards set forth by National Committee Quality Assurance (NCQA), Center for Medicare and Medicaid Services (CMS), Texas Medicaid &Healthcare Partnership (TMHP) and contracted payers. This position is responsible for submitting accurate and complete provider organizational and facilities providers enrollment applications, following up with payer credentialing departments and provider enrollment representatives to ensure providers are fully credentialed and loaded as participating with all applicable contracted health plans. Managed Care Credentialing Coordinators are accountable for maintaining and disseminating accurate plan participation status reports and billing information to all applicable Children's Health internal departments to maximize collections in the revenue cycle management process.  

Responsibilities:

• Prepare credentialing files for individual and organizational providers per NCQA, CMS, TMHP, and contracted payor standards. Perform primary source verification using pre-approved sources, documenting verification efforts consistent with Children’s Health Provider Credentialing policies. Present files to Sr. Credentialing Coordinator for review and auditing prior to Credentials Committee meetings, highlighting red-flags for peer review and discussion. 
• Obtain, verify, and maintain complete and accurate demographic information and required licensure/ certification documentation for supported individual practitioners and organizational providers. Collaborate with multiple departments to obtain and retain current copies of certificates, etc. Maintain the accuracy of the credentialing database. Maintain the accuracy of provider CAQH profiles and re-attest every 120 days. Regular monitoring of licensure for individual and organization providers to ensure updates are made in a timely for local and out of state Medicaid plans. 
• Manage the enrollment process for government plans, Medicaid Managed Care plans, and commercial plans for supported individual and organizational providers. Coordinate the gathering and verification of necessary data, working directly with practitioners or appropriate representatives. Complete applications accurately and thoroughly, meeting standards set forth by CMS, HHSC, and commercial payors. Obtain application signatures from the authorized signatory and provide all required supporting documentation. Submit applications and follow up diligently to ensure timely processing. Respond to deficiency notifications in a timely manner. Follow up diligently on provider addition requests and communicate provider changes, corrections, and terminations. Responsible for providing monthly reporting of adds, terms, and changes via delegated rosters to payers for respective assigned provider groups. 
• Create, maintain, and disseminate plan participation status and billing information to all applicable Children’s Health internal departments and 3rd party billing agencies (as applicable) to maximize collections in the revenue cycle management process. 
• Complete a quarterly roster reconciliation process for all supported practitioners with applicable health plans. Verify accuracy and communicate additions, changes, and corrections in a timely manner, along with necessary supporting documentation. 
• Support Patient Financial Services and other Children’s Health billing departments by addressing concerns regarding claim rejections/denials in a timely manner, resolving provider enrollment issues. Participate in special claim projects, coordinating with Provider Relations/Network Management as needed. 
• Maintain positive working relationships with payer representatives, providers, and all Children’s Health internal departments. 
• Perform other duties as assigned  

How You’ll Be Successful:

WORK EXPERIENCE
At least 2 years' experience in Payor Relations or Credentialing with an insurance company, hospital, or other large group of providers. Required

EDUCATION

• Two-year associate's degree or equivalent experience Required 
• Four-year bachelor's degree or equivalent experience Preferred  

Certification as a Certified Provider Credentialing Specialist (CPCS) Preferred

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute.

 Holistic Benefits – How We’ll Care for You:

· Employee portion of medical plan premiums are covered after 3 years.

· 4%-10% employee savings plan match based on tenure

· Paid Parental Leave (up to 12 weeks)

· Caregiver Leave

· Adoption and surrogacy reimbursement 

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.