Director, Provider Credentialing

3 weeks ago

Philadelphia, United States Jefferson Health Plans Full time

Why Choose Jefferson Health Plans?

We are an award-winning, not-for-profit health maintenance organization offering Medicaid, Medicare, and Children’s Health Insurance Program (CHIP) plans that include special benefits to improve the health and wellness of our members. We are committed to creating a community where everyone belongs, acknowledges, and celebrates diversity and has opportunities to grow to their fullest potential.


While this job currently provides a flexible remote option, due to in-office meetings, training as required, or other business needs, our employees are to be residents of PA or the nearby states of DE or NJ.


Perks of JHP and why you will love it here:

  • Competitive Compensation Packages, including 401(k) Savings Plan with Company Match and Profit Sharing
  • Flextime and Work-at-Home Options
  • Benefits & Wellness Program including generous Time Off
  • Impact on the communities we service

We are seeking a talented and enthusiastic Director, Provider Credentialing & Data Management to join our team

Responsible for developing, documenting, and implementing standard provider data management (PDM) and credentialing policies and procedures. Directs the activities of staff that manage the PDM and credentialing functions. The Director will work closely with Operations leadership to ensure that developed standards are communicated and implemented by all company stakeholders, including key staff who rely on using critical provider data for reporting and analytics.

As the Director, Provider Credentialing & Data Management , your daily duties may include:

  • Develop and implement a provider data governance strategy, integrating approach with various analytics teams across the organization to maximize the value of the provider data model.
  • Responsible for oversight of cross-functional and interdepartmental teams to ensure that provider data management and credentialing methodologies are consistent with the regulatory, accreditation and internal requirements.
  • Drive development and implementation of provider data interfaces, solutions, and auditable monitoring processes that include control and balance, exception handling, tracking, trending, and reporting.
  • Responsible for development, implementation, and management of operational, service, and performance metrics and proactive initiation of performance improvement activities
  • Optimize end-to-end workflows to allow for high percentage of automation, continuously improving processing turn-around times and quality of work.
  • Develop and maintain departmental policies, procedures and controls governing the credentialing process and the recording of provider data ensuring all policies and procedures and controls are in place, current, consistent across department and compliant with all legal, Federal, State, and NCQA standards.
  • Maintains up-to-date knowledge of regulations and policies related to provider enrollment and credentialing at the Federal, State and Accreditation levels and acts as the Subject Matter Expert (SME) for credentialing processes and systems, providing guidance and support to staff and internal stakeholders to ensure compliance and efficiency.
  • Oversight of the pre-delegation and ongoing delegation oversight processes related to contracted Delegated Provider entities.
  • Ensures compliance with Model Audit Rules, State, Federal and Accrediting Agencies for all elements related to provider credentialing and data entry into claims system.
  • Ensure ongoing management of provider data by overseeing and/or conducting regular audits to ensure the accuracy and integrity of provider information in provider directories, PDM and credentialing systems, collaborating data management teams to develop and implement data quality initiatives, automate data entry processes, and resolve data discrepancies efficiently.
  • Lead new business initiatives, ensuring required system configurations are planned out, implemented, tested and ready for Go Live. Ensure overall data quality, accuracy, completeness, and compliance with regulatory requirements and service level agreements.
  • Recruit, develop, motivate and retain a high caliber of team members.
  • Coach and lead team to continuously improve operational performance.
  • Maintain a positive work environment that supports self-direction; provide a structure to optimize experience, skill, knowledge and capability of the team.
  • Perform other duties as assigned.

Qualifications We Value:

Education:

  • Bachelor’s degree in business, or healthcare administration, or equivalent work experience
  • NAMSS Certification (CPCS or CPMSM) highly preferred

Skills/Abilities:

  • 8 years leading an integrated credentialing and provider data management team.
  • Working knowledge of the impact of provider data on claim adjudication, authorizations, and other operational outcomes
  • Experience implementing an end-to-end provider life cycle management platform preferred.
  • Experience managing provider data in HealthEdge HealthRules Payer preferred.
  • Working experience with mainframe systems as well as PC based applications such as Excel, Access, and Word.
  • Working knowledge of and experience in developing and managing budgets preferred.
  • Excellent organizational, interpersonal, multitasking, time management and written and oral communication skills.
  • Ability to work independently and part of a team. Strong negotiation and conflict resolution skills required.
  • Process and project management ability.

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