Credentialing Manager

MAJOR FUNCTION

The Credentialing Manager is responsible for overseeing all aspects of credentialing applications and renewals for health care professionals. This position develops, implements, and monitors policies and procedures that support credentialing, re-credentialing, data management and delegated credentialing contract processes. The Credentialing Manager manages all credentialing functions including application management and primary source verification, ensures compliance with appropriate accrediting and regulatory agencies, supervises credentialing staff, and oversees credentialing workflows and/or services provided by third party vendors as appropriate. The Credentialing Manager will conduct all aspects of third-party credentialing for providers and facilities in accordance with CMS, FQHC (Federally Qualified Health Center) and third-party insurance standards.

ESSENTIAL FUNCTIONS

• Manages credentialing processes for all LIPs, OLCPs and facilities in accordance with CMS accreditation standards, Federal and State laws, payer requirements, and all applicable external regulatory bodies.
• Develops, implements and monitors policies and procedures to ensure timely and compliant external credentialing of all LIPs
• Tracks and reports Key Performance Indicators (KPIs); participates in HJAHC’s Continuous Quality, Performance and Risk Management Plan (CQPRM) by committee attendance and QA/QI participation as appropriate.
• Prepares and maintains credentialing files and reports for all LIPs and OLCPs including maintenance of credentialing software, facility rosters and spreadsheets to comply with group delegation requirements.
• Processes and files applications with all third party payers according to each payer’s individual requirements, addresses/corrects discrepancies as requested by payers, and conducts all follow up steps until payer approval/completion is obtained.
• Monitors and reports turnaround times for processing of credentials applications, with continued focus on delivery of a high quality product, with the greatest efficiency, in the least amount of time.
• Files applicable provider practice change notifications and performs follow up duties until confirmed complete by payers.
• Updates NPI records according to provider specifications.
• Coordinates the management of the expirable process to ensure all clinical provider licenses and certificates remain current, ensuring appropriate notification prior to expiration. This includes appropriate updates to CAQH and payers.
• Accepts and processes all requests from payers for credentialing information/updates/new contracts and products.
• Answers questions, process requests from staff/providers related to credentialing information.
• Address enrollment disconnects regarding facility and providers.
• Prepares for and coordinates credentialing audits in compliance with payer credentialing contracts.
• Assists with EHRS enrollment, tracking and filing.
• Maintains quarterly payer specific rosters in accordance with CMS standards.
• Assists in quarterly CAQH mass attestation.
• Serves as liaison between Legacy and outside organizations and external customers.
• Participates in the Performance Improvement Program.

• Performs other duties and assumes other responsibilities as apparent and/or as assigned by Director of Human Resources. Duties, responsibilities and activities may change or new ones may be assigned at any time with or without notice.

Requirements

EDUCATION & EXPERIENCE:

• Bachelor’s degree in business, human resource or related field required or six years of work experience in a related field in lieu of Bachelor’s degree.
• At least five years’ experience in capacity as credentialing coordinator or credentialing specialist
• FQHC experience preferred and/or experience in an ambulatory care setting.
• Experience in payor credentialing preferred.
• High energy and enthusiasm, positive, “can-do” attitude with a high degree of initiative
• Must be able to work in a team environment and collaborative environment.
• High attention to detail
• Passion and commitment to community health
• Demonstrated ability to use Microsoft Office applications, including Microsoft Word, Outlook,
• Excel and PowerPoint
• Have good working knowledge of guidelines and requirements of agencies and carriers.
• FQHC credentialing experience is a plus.
• Must have strong, clear communication skills.
• Detailed oriented and organizational skills required.

KNOWLEDGE, SKILLS, ABILITIES AND OTHER EXPERIENCE

PHYSICAL & WORK REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

This position requires manual dexterity sufficient to operate phones, computers, and other office equipment. The position requires the physical ability to kneel, bend, and perform light lifting. This person must have the ability to write and speak clearly using the English language to convey information and be able to hear at normal speaking levels both in person and over the telephone. Specific vision abilities required by this job include close vision, depth perception and the ability to adjust focus. The working conditions are good with little or no exposure to extremes in health, safety hazards and/or hazardous materials.