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Credentialing Manager

3 months ago

Long Beach, United States Advanced Medical Manage Full time
Job DescriptionJob Description

POSITION SUMMARY

The Credentialing Manager is responsible for managing a team of credentialing professionals and is accountable for systems and processes that ensure compliance with organizational credentialing policies and procedures, and compliance with the credentialing requirements of our health plan partners, and related regulatory and accrediting agency requirements. This individual will oversee the initial and ongoing application process for all clinicians and is responsible for: maintaining the organization’s credentialing databases and online systems, maintaining up-to-date credential files, and managing all health plan enrollments and reappointments, as well as, managing all initial and ongoing applications for medical staff privileges at the contracted facilities and clinics.

RESPONSIBILITIES-DUTIES

  • Reports to Senior VP, Operations.
  • Ensure compliance with AMM’s credentialing and recredentialing policies and procedures, and compliance with state, federal, accreditation and health plan credentialing requirements.
  • Collaborate with leadership on policy development and standardization of criteria/processes across the organization.
  • Maintain and ensure up-to-date credentialing files.
  • Responsible for the accuracy and integrity of credentialing files, credentialing database and reporting systems.
  • Monitors external credential databases, including CAQH, PECOS and other regulatory agencies, to ensure data is updated and ready for quick retrieval and use by interested parties.
  • Ensure credentialing files are complete before presentation to credentialing committee.
  • Provide consultation to credentialing committee/leadership on issues related to consideration of clinical credentials and reappointments.
  • Oversee compliance with health plan requirements related to delegated credentialing agreements and credentialing file audits.
  • Oversee processes and reviews all reports related to adverse actions such as sanctions, licensure actions or limitations, and credentialing-related complaints.
  • Interview, hire and train new staff on credentialing and recredentialing policies and procedures; also provides ongoing training as needed regarding new guidelines or updated processes/policies.
  • Daily monitoring of employee’s workload and various credentialing work streams (e.g. onboarding, credentialing, pharmacy, medical staff privileging, Medicare/Medicaid enrollments, credentialing committee meetings, health plan enrollments, etc.).
  • Play an important role in making decisions regarding employee’s performance issues such as the need for disciplinary counseling, performance documentation and/or termination.
  • Conducts periodic audits of credentialing files and staff work-product.
  • Oversees initial applications and reappointments for Medicare/Medicaid enrollment, hospitals, surgical centers and managed care entities for assigned divisions.
  • Develops and provides regular reports and presentations concerning the operation and progress of the credentialing functions, including activity related to approvals, denials and/or appeals.

OTHER RESPONSIBILITIES MAY INCLUDE:

  • Monitor renewals of licensure and other documents subject to expiration, and ensures updates are forwarded to facilities and healthcare partners as renewals are received.
  • Oversee and coordinate health plan meetings if needed.
  • Work with leadership to identify and implement best practices related to credentialing.
  • Responds to facilities and health plan inquiries, interfaces with internal staff and external customers on day-to-day credentialing issues.
  • Collaborates with leadership on submitting and maintaining up-to-date health plan rosters.
  • Responsible for management and supervision of credentialing staff/team.
  • Upon request of supervisor, attends meetings with payer representatives to address outstanding issues.
  • Respond to internal/external request for credentialing and licensing status.
  • Develop reports to present to the leadership staff as requested.
  • Other activities as outlined in the credentialing and recredentialing policies and procedures.
  • Other duties as assigned and modified at manager’s discretion.

EDUCATION & EXPERIENCE REQUIREMENTS

  • Minimum 5 years healthcare experience in managed care credentialing and 1 year supervisory experience.
  • Bachelor’s degree in business administration or health care related field required.
  • Strong understanding and use of web-based credentialing applications. Experience with MD staff preferred.
  • Working knowledge of NCQA, AAAHC, JCAHO, AOA, URAC and other applicable accreditation and regulatory standards.
  • Database management skills including querying, reporting, and document generation.
  • Certified Provider Credentialing Specialist (CPCS) preferred.