Scottsdale, Arizona
Manager, Credentialing (Physician & Med personnel credential... Job Opening in Scottsdale, Arizona - CREDENTIALING MANAGER
Our client, a premier provider of information-driven healthcare services and solutions that deliver unparalleled quality and value to payers, providers, and plan members, is seeking a Credentialing Manager
The Manager, Credentialing (Manager) participates in and supervises the daily operations and activities of our Client?s Credentialing Department to:
Ensure that practitioner credentialing applications are processed accurately, in a timely manner and in accordance with NCQA and CMS standards and guidelines.
The Manager is responsible for assisting in managing relationships with client health plans, network management personnel and oversight of processes involving credentialing, practitioner enrollment and delegated credentialing agreements on behalf of the Client.
This Manager also has accountability for delegation oversight of those entities to which the credentialing
function has been sub-delegated.
The position provides managerial support to the Credentialing Committee and is responsible for enforcing the established practitioner appeal process.
The Manager collaborates with internal department staff to identify barriers to timely application processing and offers suggestions for improvement on a system wide basis.
The Manager is responsible for the completion of client health plan initiatives and monitors progress with established goals and metrics.
The Manager works closely and cooperatively with Recruitment and provides ongoing supervision of the Credentialing Supervisor(s), Credentialing Systems Specialist(s), and Quality Specialist(s), Credentialing.
POSITION RESPONSIBILITIES
Prepare management and operational reports for internal and external customers
Communicate and work to improve interdepartmental relationships with Credentialing, Recruitment, Human Resources, Logistics, Client Services, Billing, Business Operations and other designated units
Assist in the review, development and maintenance of Credentialing Policies and Procedures, desktop policies and advises on the development of critical corporate guidelines and best practices
Conduct delegation oversight reviews and audits of contracted sub-delegates, provides reports to
the client health plans in accordance with contractual provisions; prepare reports for the Credentials Committee, Quality Improvement and Compliance Committees; responsible for timely and accurate review and implementation of corrective action plans established by client health plans and/or internal departments
Complete ongoing file review on an intermittent basis to identify objectives, error rates and use data as an opportunity to counsel staff, as appropriate
Establish and maintain production and quality metrics for Credentialing Specialist(s) and/or Credentialing Assistant(s)
Research and analyze complex issues, ensure appropriate documentation to identify outcomes and accurately interpret internal and external guidelines and policies
Develop, implement and manage processes to create, update and maintain practitioner files for enrollment purposes and for ensuring accurate and timely completion of credentialing and practitioner enrollment
Effect interdepartmental collaboration and coordination to maximize efficiency and effectiveness of practitioner credentialing and enrollment as well as to maintain documentation necessary for verification, accreditation and credentialing delegation of the organization
Facilitate problem solving of operational issues through collaboration with client health plans and internal stakeholders
Identify and communicate all concerns regarding practitioner credentialing and enrollment, including excessive timeframes for outstanding applications to the , Human Resources, Resource Planning & Administration, Production Planning & Control, Account Management, Billing, Business Operations and other designated units
Make recommendations for optimizing contract language as it relates to credentialing, practitioner enrollment and delegated credentialing
Manage multiple projects simultaneously and under tight deadlines
Resolve contract and claim issues related to practitioner enrollment and identify and communicate opportunities for process improvement
Respond to inquiries regarding practitioner credentialing and enrollment
Track applications through the practitioner credentialing and enrollment process with the client health plans to ensure timely processing until credentialing is complete and practitioner enrollment effective dates are obtained prior to or as close as possible to the practitioner start date
Manage special studies and/or projects related to practitioner on-boarding, credentialing and client health plan practitioner enrollment and prepare report of findings and recommendations as appropriate
Collaborate with the Legal Department to obtain copies of client health plan contracts, review for credentialing requirement compliance, advise Director and Senior Legal Counsel of any exceptions or lack thereof and develop time sensitive corrective action plan(s) to address and remedy deficiencies
Effective improvement of operational processes to achieve maximum efficiency, accuracy and data integrity
Participate in the internal monitoring of Chapters 11 and 13 of the Medicare Managed Care Manual
Ensure compliance with NCQA and CMS standards and guidelines; identify and monitor The Joint Commission, URAC, AAAHC accreditation policies and other federal and state legislation, as appropriate
Develop agenda and supplemental materials for the Credentials Committee and prepare ad hoc reports for the Quality Improvement and Compliance Committees
Provide management support to key Credentialing staff, both direct and indirect reports
Maintain confidentiality of all credentialing information in compliance with federal and state statutes, as well as Matrix policies
Support professional development of Credentialing staff
Perform miscellaneous job-related duties as assigned
Educational Requirements
Bachelor?s in Business, Finance, Health Care or related field preferred; or high school diploma and appropriate combination of education and experience
Required Skills and Abilities
Must have managed a large Credentialing team--No Dr. office credentialing
Must have processed hundreds of physician and med personnel credentials and have supervised that whole process
Must have the Credentialing Manager title not HR Manager nor Revenue cycle or billing Manager
Minimum of three years of experience with credentialing in a Medicare Managed Care Plan or large provider group with Medicare contracts; or up to three years of experience in a health care setting, including two years of practitioner enrollment, credentialing or provider network management experience
Participation in CMS credentialing audits or experience conducting CMS related internal compliance audits
Experience in developing and implementing policies and procedures, desktop procedures and work flow diagrams
Experience in training, educating and coaching department staff as well as internal and external customers to achieve streamlined process and meet corporate goals
Experience with medical and professional credentialing processes, policies and procedures, including delegated credentialing requirements
Familiarity with practitioner billing and claims payment system requirements as related to practitioner enrollment
Effective leadership skills at all levels
Ability to interface and collaborate with internal and external professionals, including accreditation and government regulation representatives
Exceptional verbal and written communication aptitude, with proven ability to positively influence behavior
Conflict resolution and change management competence
Process and operational improvement experience
Independent and logical processing proficiency
Highly self-directed, motivated and able to work independently with minimum level of supervision
Professional, courteous demeanor and attire
Excellent administrative and organizational skills
Detail oriented while keeping broader perspectives in sight
Strong computer skills a necessity
Excellent analytical, data aggregation and customer service skills required
High level of proficiency with Microsoft Office programs and the internet
Demonstrated ability to work independently
Ability to manage multiple projects efficiently and accurately
Strong analytical skills needed to assess compliance, record, analyze and interpret data into meaningful formats
Strong written and verbal communication skills
Demonstrate ability and commitment to excellent customer service to develop and maintain effective working relationships with internal and external clients
Able to effectively manage conflicting priorities, adapt to ever changing responsibilities and meet highly structured deadlines
Exceptional attention to detail and accuracy
Excellent critical thinking skills, professionalism, reliable judgment and the ability to communicate in an articulate and sensitive manner with practitioners, administrators, legal counsel, team members and client health plans
Preferred
Minimum of three years of progressive management experience required; five years of progressive management experience strongly preferred
Current Certified Practitioner Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) designation through the National Association of Medical Staff Services (NAMSS)
Experience with MD-Staff or similar practitioner credentialing, data collection and record management system
Experience with NCQA, URAC, The Joint Commission and/or AAAHC guidelines and standards related to credentialing and delegation
Proficiency with Microsoft Office programs
Supervisory Responsibility
Direct management and oversight responsibility for Credentialing Team, including Credentialing Specialist(s), Credentialing Assistant(s), and other department personnel
BENEFITS (for you and your family!):
Medical
Dental
Vision
Group Life & AD&D
Voluntary Life Insurance
Disability
Care24 Employee Assistance Program (EAP)
Legal & Identity Theft
Flexible Spending Accounts
Job Type: Full-time
Salary: $70,000.00 to $82,000.00 /year
Required education:
High school or equivalent
Required experience:
health care setting: 3 years
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