MAIN FUNCTIONS:

• Responsible for all aspects of the verification process for medical staff
• Develops and implements policies and protocols related to physician, nurse and other employee verifications
• Ensures that the organization and staff are in accordance with all standards
• Resolving escalated issues within the department
• Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion with time periods specified
• Leads, coordinates and monitors the review and analysis of practitioner applications and accompanying documents ensuring applicant eligibility
• Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures resolution
• Administer credentialing audits and conducts internal file audits
• Monitors the initial, reappointment and expirable process for all medical staff, Allied Health Professional staff, other health professional staff and delegated providers
• Ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, Federal and State) as well as medical staff Bylaws, Rules and Regulations
• Develop and trains staff on regulations, policies and procedures
• Responsible for the regular review of internal processes in order to evaluate quality and efficiency within the Managed Care Department; recommend, administer and implement multiple activities in support of the Managed Care Department initiatives.
• Responsible for the regular review of internal processes in order to evaluate quality and efficiency within the Managed Care Department; recommend, administer and implement multiple activities in support of the Managed Care Department initiatives.
• Work with Managed Care Leadership to find efficiencies that will improve processes and communication.
• As a working supervisor, research and respond to routine, non-routine, complex and escalated inquiries in a timely and professional manner.
• Work with various departments to prevent issues as well as resolve elevated billing, reimbursement, health plan participation and credentialing issues.
• Maintain awareness of Payor Managed Care activities for changes in policies, authorization requirements and other processes that impact the Practice.
• Maintain the Payor matrix, including limited network participation, to ensure information is accurate and up to date.
• Maintain standard operating processes and procedures for contract monitoring and renewals.
• Gather current data and monitors changes on plan membership, patient volume, plan/benefit structure, reimbursement and other information needed to complete the contract profile.
• Review fee schedules for accuracy and identifies significant changes in reimbursement.
• Oversee activities responsible for ensuring that all Providers are credentialed with Payors and Hospitals in a timely and accurate fashion.
• Promptly communicate credentialing status to applicable parties.
• Monitor Payor directories to ensure all providers are listed accurately by plan
• Monitor trends to avoid minor issues from having a major impact on reimbursement and collections.
• Other duties as assigned.

EDUCATION: 

• Bachelor’s Degree or equivalent professional experience in Healthcare
• CPMSM and/or CPCS Certification

EXPERIENCE:

• Five or more years in healthcare managed care contracting experience
• Working knowledge of both Managed Care and Provider Insurance Credentialing
• Working knowledge of government and non-government insurance, payer requirements, and healthcare operations
• Excellent knowledge of healthcare revenue cycle, healthcare finance, CMS and state regulations and healthcare compliance requirements/activities

• Competitive compensation based on experience and qualifications: When determining the compensation, several factors may be considered including, years of relevant experience, credentials, union contracts, education, and internal equity.
• Comprehensive health, dental, and vision insurance
• 401K, Retirement savings plan with employer contribution
• Generous Paid Time Off (PTO) and paid holidays
• Tuition Reimbursement
• Opportunities for professional growth, development, and continuing education
• Employee wellness programs and resources

Influenza Vaccinations are a requirement for employment. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date, during the influenza season, if you are offered employment, unless you request and receive an approved medical exemption.