The Mgr, Credentialing leads a team responsible for all elements of the Credentialing, Recredentialing, and/or Delegated Credentialing processes. The Mgr, Credentialing will ensure ongoing execution of credentialing and other applicable provider onboarding functions completed are in accordance with applicable department policies and procedures.
Responsibilities- Lead Credentialing Team day to day activities while planning / executing for long-term growth
- Mentor, develop, and train team members as well as educate the PDS team or field team members (affiliated clinical and operational) on the carrier and plan credentialing nuances
- Ensure and maintain PDS compliance with all doctor's credentials and licenses
- Manage the credentialing process in accordance with NCQA, CMS, federal and state laws/standards
- Develop and provide reporting and subject matter expertise to field and PDS team members including status reports, out-of-network reporting, re-credentialing updates, etc.
- Develop and provide reporting to measure the throughput of the credentialing team, ensure timeliness and accuracy of all credentialing processes, and gap analysis for improvement
- Partner with the billing department and Epic team to ensure all credentials are loaded timely
- Establish and build relationships as the primary point of contact with insurance plan representatives
- Analyze insurance plan trends that may impact the business (e.g., credentialing alternatives and competitors, the potential impact of the Affordable Care Act, etc.). make recommendations to optimize the credentialing process
- Facilitate the credentialing team's coordination and communication with the onboarding of new doctors and all departments, including Legal, People Services, DeNovo, and field leadership
- Collaborate with billing and patient relations departments on denials, downgrades, or other anomalies to align billing practices with insurance carrier requirements that improve care and reduce overall cost
- Oversee the development and maintenance of training programs, manuals, and all field/clinician-facing collateral
- Lead/coordinate projects and special assignments as required by planning and identifying opportunities for process improvement/efficiency
- Ensure alignment with the maintenance of audit procedures, including process adherence, document tracking, records, reports, policies, and procedures for accuracy and effectiveness
- Other duties as assigned by management
Qualifications- Bachelor's Degree or one-year certificate from an accredited college or technical school; or equivalent combination of education and experience, and 4-6 years of related business experience. In lieu of education, 8+ years of experience is required
- Experience in assessing workflow, leading a team, mentoring, coaching, and training subordinate
Preferred- Experience in a multi-regional healthcare, retail, or dental company
- Credentialing leadership with proven results
Knowledge/Skills/Abilities- Strong abilities in managing the daily operations of department(s) or work unit while developing short to medium term (1-3 years) goals
- Fostering employee development by providing a supportive learning environment
- Highly developed teambuilding, influencing, and collaboration skills
- Ability to direct the work of others and work as a team leader in attainment of goals
- Ability to interpret and apply policies and procedures
- Ability to handle and maintain extreme confidentially with employee records, compensation information, etc.
- Ability to draw valid conclusions; apply sound judgment in making decisions, and make decisions under pressure
- Proficient communication skills with a commitment to achieving predetermined goals
- Ability to read, analyze, and interpret documents such as professionals journals, technical procedure manuals, safety rules, operating and maintenance instructions, and governmental regulations
- Ability to interpret a variety of instructions furnished in written, verbal or diagram form
Benefits- Medical, dental, and vision insurance
- Paid time off
- Tuition Reimbursement
- 401K
- Paid time to volunteer in your local community
Compensation Information
$93,000.00-$117,000.00 / Annually
