Position purposeResponsible for the oversight of the credentialing and recredentialing application process for health care providers with all health plans. The position is also responsible for ensuring compliance with credentialing guidelines for NCQA and understanding the credentialing processes for each of the health plans GI Alliance is contracted with. The Credentialing Manager will assist the Director of Payer Relations and SVP of Payer Relations with implementing new providers and ensure credentialing activities are complete prior to their effective date with GI Alliance. This position will assist with developing credentialing policies and procedures.
Responsibilities/Duties/Functions/Tasks:
- Approve time off requests, ensuring adequate staffing during peak times
- Review and approve semi-monthly payroll
- Provide employee feedback, coaching, and counseling
- Conduct annual employee performance reviews and deliver reviews to employees
- Attend management meetings, as needed
- Ensure providers credentialing is completed prior to the effective date with the health plans.
- Assist with training and educating credentialing staff and provider offices on credentialing processes.
- Assist COO and Director of Payer Relations as needed for any escalated issues related to credentialing GI Alliance providers.
- Other duties as assigned
Essential Job Functions:
- Handles all integration and enrollment for incoming providers are completed by the requested timeline.
- Compiles and maintains current and accurate credentialing data for all providers.
- Completes provider credentialing and recredentialing applications; monitors applications and follows-up as needed.
- Handles any escalated credentialing issues to include any retro activity requests made to the health plans. Appropriately escalates the issues to the Director and SVP of Payer Relations as needed to assist in resolving outstanding issues.
- Ensures credentialing staff maintain appropriate copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.
- Maintains corporate provider credentialing files.
- Maintains knowledge of current health plan and agency requirements for credentialing
providers
- Sets up and maintains provider information in online credentialing databases and system.
- Tracks license and certification expirations for all providers to ensure timely renewals.
- Ensures the data accuracy of practice demographics, to include addresses, phone numbers, fax numbers, etc. are current with health plans, agencies, and other entities.
- Ensure health plan provider directories accurately reflect our providers and for the correct health plans that we are contracted with
- General knowledge of health plan contracts (HMO, PPO, and Government plans)
- Other duties as assigned.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
Qualifications Education: High school diploma or equivalent.
Experience: Minimum of seven 7) to ten (10) years of credentialing experience preferred.
Additional Qualifications: N/A
Performance Requirements: - Strong presentation skills.
- Excellent communication skills, both written and verbal.
- Ability to work with physicians and non-physician providers.
- Proficient technical (computer) skills.
- Ability to multi-task and prioritize.
- Self-motivated with initiative.
- Strong sense of ethics.
Equipment Operated: This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.
Work Environment: This job operates in professional office environments.
