Credentialing Coordinator

MetroPlus Health Plan provides the highest quality healthcare services to residents of Bronx, Brooklyn, Manhattan, Queens and Staten Island through a comprehensive list of products, including, but not limited to, New York State Medicaid Managed Care, Medicare, Child Health Plus, Exchange, Partnership in Care, MetroPlus Gold, Essential Plan, etc. As a wholly-owned subsidiary of NYC Health + Hospitals, the largest public health system in the United States, MetroPlus’ network includes over 27,000 primary care providers, specialists and participating clinics. For more than 30 years, MetroPlus has been committed to building strong relationships with its members and providers to enable New Yorkers to live their healthiest life. 

Position Overview

MetroPlus Health Plan is seeking an individual to join our Provider Services team in the capacity of Credentialing Coordinator. The responsibilities of this position include but are not limited to perform most tasks related to the credentialing of new providers, primarily for Behavioral Health, including document collection and verification, and provider credentialing file maintenance. Also ensure that all credentialing supporting documentation is confidential and maintained in a secure environment. As well as assisting facilities and providers in understanding and adhering to MetroPlus’ policies and procedures regarding the credentialing process.

Primary focus will be on recruitment and credentialing of Behavioral Health providers.

• Maintain communication with the credentialing contacts at facilities and provider sites to coordinate receipt of information required for credentialing, re-credentialing, and update of provider credentialing information
• Review provider re-credentialing and credentialing file for completion and presentation to the Credentialing Committee.
• Perform primary source verification on required elements and in accordance regulatory guidelines and MetroPlus’ policies and procedures
• Data entry and upkeep of provider information in the credentialing and other pertinent databases
• Verify New York State OPMC, Medicare/Medicaid lists and other pertinent databases for any current sanctions, restrictions on licensure and/or limitations on the scope of practice on all credentialed providers in interim credentialing periods
• Verify New York State license registration and DEA registration status for all credentialed providers in the interim credentialing periods
• Generate and disseminate monthly provider credentialing updates to appropriate departments at MetroPlus Health Plan and participating facilities and provider groups
• Review and respond to request for credentialing information/copies of credentialing files to appropriate departments within MetroPlus
• Generate and disseminate provider rosters to delegated facilities, contracted group practices etc.
• Perform provider roster reconciliation
• Create, copy, file, and maintain all relevant documentation into provider credentialing folder.
• Maintain confidentiality of provider credentials by filing the credentialing folder in respective cabinets in the file rooms.
• Perform annual delegated file audits and participate in pre-delegation and delegation site  reviews
• Respond to inquiries from other MetroPlus departments relative to a provider’s credentialing status
• Performs other related tasks as directed by the AED of Network & Provider Contracting or his designee and the Credentialing Director

• Bachelor’s Degree preferred
• Excellent communication and organizational skills
• Previous experience with provider credentialing processes and procedures
• Knowledge of NYC H+H credentialing policies and procedures preferred
• Good computer skills and able to work with MS Office
• Knowledge of CACTUS preferred
• Must be able to handle multiple projects simultaneously.
• Comprehensive knowledge of managed care with a specific emphasis on physician credentialing.
• Ability to meet time-sensitive deadlines and multi-task in a changing healthcare environment.
• Excellent communication (both verbal and written) and organizational skills.
• Understanding of credentialing activities as they relate to initial credentialing, re-credentialing and credentials modification(s).
• Proficient in Microsoft Office (Word, Excel, Access).

Professional Competencies

• Integrity and Trust
• Customer Focus
• Functional/Technical skills
• Written/Oral Communication