DescriptionHybrid role:- Externalapplicants must be a California resident as of their first day of employment.
- Internal applicants must live in their current approved state (The 6 approved states: CA, AZ, NV, TX, WA, OR).
PRINCIPAL RESPONSIBILITIES:Under the supervision of the Executive Director Network Operations, the Sr. Manager, Peer Review and Credentialing is responsible for oversight and administrative management of the Alameda Alliance credentialing process for physicians, allied health practitioners, ancillary practitioners and organizational providers. The position is also reponsible for the supervision of peer review and credentialing staff and credentialing vendors. Addtionally, this position provides credentialing oversight of the delegated entities. The function of Peer Review and Credentialing is to support compliance with NCQA, CMS, DHCS, DMHC, and other regulatory agencies relative to all functions of credentialing.
Principal responsibilities include:
- Manage oversight and supervision of credentialing and peer review staff to ensure compliance and timely processing of new provider and recredentialing applications.
- Primary resource in credentialing, quality assurance/performance improvement credentialing requirements, and department and committee activities.
- Maximize the credentialing and peer review team's efficiency, productivity, and performance by keeping employees accountable for meeting credentialing guidelines.
- Manages the credentialing vendors including Cactus, CVO, and CAQH services. Conducts audits on all reports and files to ensure compliance, reviews invoices for their accuracy, and approves payment. Implement Corrective Action Plans when required.
- Perform periodic file audits to ensure that credentialing procedures meet regulatory requirements and Alliance standards, and credentialing files are complete.
- Manages ongoing reporting process that is accurate, timely, and action driven that support the credentialing staff.
- Collaborate with the Chief Medical Officer to ensure that all significant malpractice cases, state/federal sanctions, and quality issues are reviewed prior to peer review.
- Manage ongoing monitoring as required by regulatory agencies.
- Interpretes, develops, and implements practices of all credentialing systems and functions to ensure continuous compliance with applicable regulatory agencies and accrediting bodies, e.g., NCQA, DMHC, DHCS, CMS, etc
- Perform delegated entity annual credentialing audits and review quarterly credentialing reports as required by regulatory agencies. Implement Corrective Action Plans as required. Summarize and submit reports to CMO and Compliance Department as requested.
- Primary contact for internal credentialing audits as required. Act as a resource on credentialing regulatory requirements.
- Responsible for coordination and submission of the Peer Review and Credentialing Committee including coordination auditing files and preparation of materials, preparation of agenda, and conduct follow up from Peer Review and Credentialing Committee meetings.
- Manage and oversee that credentialing staff contact providers and outside agencies through written and verbal communication in order to obtain and prepare credentialing documentation for review and completion of application or to update credentialing records.
- Contact providers through written and verbal communication in order to prepare credentialing documentation.
- Coordinate with Network Management and Quality Management department staff to ensure timely submission of grievances, quality issues, and facility site review data as part of the recredentialing and on an ongoing basis.
- Ensure compliance with Alliance established policies and procedures, objectives, and Quality Improvement Program.
- Responsible for developing credentialing policies and procedures.
- Review and update Alliance credentialing policies, workflows, and training manual annually and as needed.
- Coordinate the credentialing process with the Compliance department and Network Management.
- Manage maintenance of practitioner and organizational provider information in the Alliance information system and assures confidentiality of that information.
- Responsible for controlling costs and budgeting for the Credentialing department and ensuring funds get used appropriately.
- Oversee employee performance. Responsible for employee improvement action plans.
- Complete special projects and other duties as assigned.
ESSENTIAL FUNCTIONS OF THE JOB:- Access a variety of sources including computer related sources and paper files. Review information in files/computer and report details back to provider or Alliance staff as appropriate.
- Serve as liaison between the provider and health plan member.
- Prepare and administer presentations to providers for training and promotional purposes.
- Travel between the worksite and provider/delegated entity offices is required.
- Supervise and train staff.
- Perform writing, administration, analysis, and report preparation.
- Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
PHYSICAL REQUIREMENTS- Constant and close visual work at desk or computer.
- Constant sitting and working at desk.
- Constant data entry using keyboard and/or mouse.
- Frequent use of telephone headset.
- Constant verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
- Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
- Frequent walking and standing.
- Occasional driving of automobiles.
Number of Employees Supervised: 1 - 3
MINIMUM QUALIFICATIONSEDUCATION OR TRAINING EQUIVALENT TO:
- BA/BS Degree required or equivalent years of credentialing work experience.
- Current NAMSS certification in Certified Provider Credentialing Specialist (CPCS) and/or Credentialing Professional Medical Staff Management (CPMSM) required.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:- Minimum five years of previous experience in credentialing within a health care/managed care environment.
- Minimum three to five years supervisory experience required.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):- Knowledge of CMS, DHCS, DMHC, NCQA standards, and Title XXII standards required.
- Excellent interpersonal and persuasive communication skills.
- Excellent work ethics, organizational skills, and orientation to detail.
- Familiarity and knowledge of credentialing database.
- Ability to work independently.
- Experience in use of Microsoft Office suite including Access
SALARY RANGE: $181,337.52 - $272,006.28 Annually 
