Credentialing and Payer Enrollment Analyst

Company: Carolinas MGMA
Location: San Francisco
Posted on: April 10, 2025

Job Description:

Job SummaryThis position will serve as a processing analyst for the University, analyzing, evaluating, processing, and self-audits applications according to appropriate membership, privileges, and health plan enrollments for UCSF Medical Staff, Advanced Practice Professionals and CVO contracted facilities (LPPH&C, School of Dentistry, UCSF Benioff Children's Physicians (UBCP), Clinically Integrated Network (CIN) Partners, Benioff Children's Hospital - Oakland and others, as applicable). This position will also process provider enrollment applications for UCSF billing physicians, Advanced Practice Providers, and Clinical Partners/Affiliates. This position will ensure all provider health plan enrollment applications are accurate and compliant. Implements policy and procedures, provides training and orientations to various constituents, and supports efforts to sustain best practices.

• Manage and perform administrative and analytical tasks to credential new and reappointing providers who apply/reapply to practice at UCSF or within UCSF Health network. Ensure file completeness, analyzing for time gaps, checking appropriate licensure, obtaining peer references, and verifying additional required credentialing items. Reconciling and resolving discrepant information obtained during the credentialing process is of the utmost importance. Consistent communication with applicants, colleagues and management is crucial. Additionally, the credentialing process may also require liaising with other teams, various UCSF departments/managers to ensure an integrated, timely, and accurate credentialing workflow.
• Prepares and submits provider health plan enrollment applications for new enrollments and revalidation with government and commercial plans. Prepares and submits Deactivation once the provider is no longer active with UCSF and has been approved for deactivation by the Governing bodies.
• Oversee/monitor submitted provider enrollment applications, monitor necessary follow ups with appropriate entities, responding to Requests for Information (RFI), and obtaining signature pages and all necessary documentation for the submission of various documents in the health plan enrollment process.
• Collaborates with the Director and Program Manager to help improve business operations, credentialing practice, enrollment practice, and systems interface.
• Works directly with the intermediaries of the Center for Medicare/Medicaid Services (CMS), The Department of Health Care Services (DHCS), and California Children's Services (CCS) to ensure submitted applications are processed correctly and in a timely manner.
• Monitors and manages Medicare and Medi-Cal revalidation applications on a random cycle of all existing billing providers, Groups/Suppliers, and UCSF Tax Identification Numbers (TIN).
• Interprets and understands current and forthcoming health plan enrollment regulations issued by Federal and State entities to ensure compliance for the University and UCSF Medical Staff Providers.
• Manage provider's primary specialty in ECHO and manage updates in National Provider Identifier (NPI) Registry such as Name change, Primary Specialty, Taxonomy, and Primary practice location (Group name, address, phone and fax number).
• Supports credentialing work queues to avoid and/or resolve health plan enrollment/credentialing related claim denials.
• Works closely with billing agents to resolve/release held claims in credentialing work queues.
• Works with billing agents and departments to ensure proper billing practice.This position is responsible for ensuring all Physician and Non-Physician profiles are accurately updated and correctly reflect credentialing and health plan enrollment statuses. Deficiencies in profiles would result in misguided information across the entire facility, improper healthcare access, and potential loss of revenue.Monitors and reports potential enrollment delays to department representatives, billing agents, and leadership.Ensures all outside UCSF Affiliates and Clinical Partners are appropriately credentialed and enrolled with government health plans, including Medicare, Medi-Cal, and California Children Services.Using effective decision making and problem-solving skills, the position is responsible for implementing functional credentialing and health plan enrollment (HPE) work flows and reporting on those functions. The incumbent must be cognizant of and able to work with the regular fluctuations in documentation, healthcare regulations as well as the ongoing development and implementation of UCSF IT systems.The incumbent must work closely with billing agents (Medical Group Business Services, Change Healthcare), government agencies and their systems/platforms (CMS, DHCS, PECOS, PAVE, NPPES, EDS), intermediaries (Noridian), and commercial health plan contracts to ensure credentialing and enrollment compliance and proper billing practices.The final salary and offer components are subject to additional approvals based on UC policy. The salary range for this position varies from $63,700-$136,100, and the target entry point is $76,800+ based on experience AND the current salary levels and experience of individuals working at UCSF in a similar role. To learn more about the benefits of working at UCSF, including total compensation, please visit: Required Qualifications
  • Bachelor's degree in a related area or four years of relevant experience.
  • Two years of experience working in a healthcare environment.
  • Knowledge of TJC, NCQA, CMS, DHS, DMHC, ACGME and other applicable accreditation/regulatory requirements.
  • Knowledge of managed care, provider enrollment/credentialing, and/or medical staff services.
  • Knowledge of relevant healthcare regulations issued by Federal and State entities.
  • Ability to interpret health plan enrollment regulations to ensure compliance.
  • Competency in a paperless computer environment and understanding of provider data integrity standards (credentialing software, MS Office suite, Adobe Professional, document scanning/storage, web-based applications and tools, etc.).
  • Ability to perform all commonly applicable functions in Microsoft Office Suite (Word, Excel, PowerPoint, OneNote, etc.), medical credentialing database application, Epic, and EMR systems.
  • Excellent ability to interact with all levels of management; communicate effectively, both verbally and in writing; and, function within a team and independently.
  • Excellent data analysis, research, and reporting skills.
  • Exceptional organizational skills and ability to set priorities as well as manage multiple demands effectively.
  • Role models and promote best practices to maintain confidentiality and discretion to preserve.
  • HIPAA/Peer review protections as well as attorney-client privilege, as warranted.
  • Knowledge of compliant revenue/billing practices to mitigate fraud/waste/abuse impacts on organization priorities/work plans.
  • The ability to work onsite in our San Francisco office when required.Preferred QualificationsCertified Professional Medical Services Management (CPMSM)License/CertificationCertified Provider Credentialing Specialist (CPCS) within 18 months of hire from OMAG required to meet performance expectations of role. About UCSFAt UCSF Health, our mission of innovative patient care, advanced technology and pioneering research is redefining what's possible for the patients we serve - a promise we share with the professionals who make up our team.Consistently ranked among the top 10 hospitals nationwide by U.S. News & World Report - UCSF Health is committed to providing the most rewarding work experience while delivering the best care available anywhere. In an environment that allows for continuous learning and opportunities for professional growth, UCSF Health offers the ideal atmosphere in which to best use your skills and talents. Pride ValuesUCSF is a diverse community made of people with many skills and talents. We seek candidates whose work experience or community service has prepared them to contribute to our commitment to professionalism, respect, integrity, diversity and excellence - also known as our PRIDE values.In addition to our PRIDE values, UCSF is committed to equity - both in how we deliver care as well as our workforce. We are committed to building a broadly diverse community, nurturing a culture that is welcoming and supportive, and engaging diverse ideas for the provision of culturally competent education, discovery, and patient care. Additional information about UCSF is available at Join us to find a rewarding career contributing to improving healthcare worldwide.
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Keywords: Carolinas MGMA, San Francisco , Credentialing and Payer Enrollment Analyst, Professions , San Francisco, California