Improving the health of our community in all we do
Northeast Georgia Health System (NGHS)is a non-profit community health system on a mission of improving the health of our community in all we do. Our team cares for more than 1 million people across the region through four hospitals and a variety of outpatient locations. Northeast Georgia Medical Center (NGMC) has campuses in Gainesville, Braselton, Winder and Dahlonega - with a total of more than 700 beds and more than 1,100 medical staff members representing more than 50 specialties. NGHS also encompasses Northeast Georgia Physicians Group, a multi-specialty group with more than 65 locations, and The Heart Center of Northeast Georgia Medical Center, a cardiology practice with more than 15 locations.
This position shall perform functions related to the enrollment in healthcare plans for practitioner and facility members of the Northeast Georgia Health Partners Network. This includes the processing for all self-funded TPA contracts, delegated payors, Medicare Advantage and Medicaid CMO's for initial credentialing & re-appointments. This position may perform credentialing functions from time to time as deemed necessary. This position shall effectively communicate pertinent information to all necessary individuals and entities in a timely and accurate manner, both internal and external to the department. This position shall posses knowledge of widely used credetialing and enrollment concepts, practices, and procedures. Relies on experience and judgment to plan and accomplish daily work. Works under general supervision.
High School Diploma or equivalent required, Bachelors degree preferred.
Five or more years experience in health care desired, minimum of two years of experience in the area of managed care, to include credentialing, provider payor enrollment and/or provider relations. Experience with enrolling providers in commercial and government payor groups strongly desired.
Essential Tasks and Responsibilities
Shall prepare documents to successfully enroll all provdier types in payor plans contracted with Health Partners for both commercial and governmental plans.
Takes the lead with payors in monitoring the progress of enrollment. Notifies management of payor noncompliance.
Follows-up with the provider, the credentials verification office and/or NGPG recruitment to secure missing documents for credentialing and enrollment purposes.
Monitors provider non-compliance with enrollment requests and notifies management of delays that can impact reimbursement.
Responsible for provider and payor roster management.
Monthly, or more often as needed, prepares and submits delegated rosters to payors in accordance with delegated agreements to ensure timely effective dates for billing and payment purposes. This includes new and changed information. Monitors receipt and follow-through.
On an ongoing basis, tracks timeliness of provider loads by payor to include date submitted, date confirmation received, error rate and corrections needed. Reports non-compliance to management for further direction. Retains communication in an orderly fashion for reference purposes.
On a monthly basis, audits provider loads once confirmed by the payor for accuracy. Report, by way of written correspondence, the errors that need to be corrected to the payor. Report findings to management. Monitor progress and resolution. Schedule conference call and/or meetings with payor representatives to address issues.
Authors and sends correspondence to payors to maintain current provider information including, but not limited to, changes in practice addresses, contact information, name changes, board status and resignations.
Sends out provider demographic update requests as directed, to the HP/HP2 network members, to maintain accurate provider data within the network's data systems and with the networks contracted payors.
Amends and updates the HP master spreadsheet, organizational documents, the website, and credentialing and enrollment systems with physician and/or physician office information with regards to additions, updates, terminations, and other information that is supplied to the HP payors for accurate claims payment.
Follows-up on rejected documents or loading from the payors. Corrects and resubmits on a timely basis. Retains records for reference purposes.
Completes and submits payor specific enrollment spreadsheets for existing providers that want to add additional practice locations or are moving from one practice to another in support of the payment process.
Monitors receipt of payor effective date notices. Contacts payors to follow-up on enrollment loading status. Enters HP effective dates into the Medicred payor enrollment system. Notifies key personnel when updates are made.
Enters and updates all provider demographics into the appropriate data repositories for tracking and reporting purposes. Notifies the CVO and/or others as necessary when changes are needed and special reports need to be captured and configured.
Maintains an accurate distribution list to include all persons that shall receive on-going information from Northeast Georgia Health Partners.
Maintains files in an orderly and secure fashion. Creates efiles to house enrollment documents and related correspondence. Initiates a provider enrollment tracking form for each provider to monitor progress.
Supports the NCQA standards and accredidation process.
Serve as a liason between the provider, staff and Health Partners in support of resolving credentialing and payor enrollment issues that arise during the initial and/or re-credentialing processes.
Builds and maintains Health Partners relationships with existing, potential and new network providers and staff's.
Will cross train and perform other duties as assigned within the department in the following areas credentialing, data integrity and provider relations.
Schedules, organizes, and coordinates all in-services and educational material for Health Partners providers regarding processes and procedures of various payors that contract with the Northeast Georgia Health Partners Network.
Shall routinely compose emails and other written material using proper grammer and sentence structure.
Shall conduct provider office visits and or other orientation and onboarding activities as directed.
Shall organize and draft material for the Newsletter as directed.
Supports management in all aspects of provider enrollment to include reporting, meeting attendance and departments projects as needed.
Since first opening its doors in Gainesville in 1951, Northeast Georgia Medical Center has added hospital campuses in Braselton, Barrow and Dahlonega - and become Georgia's most awarded hospital. Some recognitions include being named to these lists:
America's 50 Best Hospitals- Healthgrades
100 Top Hospitals- Truven Health Analytics
100 Hospitals with Great Heart Programs- Beckers Hospital Review
America's Top Quality Providers- Carechex
Atlanta's Top 150 Workplaces- Atlanta Journal-Constitution
Healthcare's Most Wired Hospitals and Health Systems- Hospitals & Health Networks magazine
NGMC has also been recognized in recent years as Georgia's #1 Hospital for overall hospital care, overall surgical care, heart care, orthopedic surgery, women's care and more.