Credentialing Manager

5 months ago

Baton Rouge, United States Louisiana Primary Care Association Full time $59,550 - $110,650
Louisiana Primary Care AssociationPosition Title:  Credentialing ManagerFulltime ExemptSupervisor:    Director of Managed Care and Network Development About Us:  The Louisiana Primary Care Association (LPCA) promotes accessible, affordable, quality primary healthcare services for the uninsured and medically underserved populations in Louisiana. It is a membership organization of Federally Qualified Health Centers (FQHCs) and supporters committed to the goal of achieving healthcare access for all. The Louisiana Primary Care Accountable Care Organization (LPCACO) was founded by 22 FQHCs and the LPCA in order to enter the Medicare Shared Savings Program (MSSP) for the 2017 program year. Position Summary:  The Credentialing Manager is responsible for overseeing the successful operations of the credentialing program of the Louisiana Primary Care Accountable Care Organization, including gaining adoption from the LPCACO member Health Centers for the core credentialing platform (CredentialStream by VerityStream), ensuring that pre-implementation activities are completed successfully, making training available to the health centers, ensuring the CredentialStream platform is configured to meet the needs of the health centers, the LPCACO, and the health plans, ensuring the integrity of the credentialing data entered by the health centers, establishing and maintaining key support functions related to the program including ongoing training, first-tier support, support escalation to the vendor, and billing and collections from the health centers for their program fees, and leading the development and implementation of approved policies and procedures for health plan delegated credentialing. The Credentialing Manager must ensure compliance with the LPCACO’s credentialing and recredentialing policies and procedures, as well as compliance with state, federal, accreditation, and health plan credentialing and enrollment requirements.  Responsibilities:Internal Credentialing 
  • Ensure that the CredentialStream platform is configured properly to support the internal credentialing requirements of each health center, standardizing where possible across health centers to develop a LPCACO best practice.
  • Review monthly CredentialStream releases to ensure system updates and enhancements continue to support a stable CredentialStream environment. Communicate important changes to all participants and provide end-user training and support as needed.  
  • Ensure that the workflows and processes supported by CredentialStream will meet the credentialing and privileging files for all licensed and certified staff in compliance with Federal Tort Claims Act (FTCA) requirements.
  • Assist new and renewing providers with privileging and credentialing applications; monitor completion and follow-up as needed.
  • Maintain licensed staff information in a centralized location. 
  • Track license and certification expirations for all licensed staff to ensure timely renewals.
  • Work with the Chief Medical Officer to process applications for appointment and reappointment of privileges.
  • Track expirations and maintain current copies of licenses, DEA, board certifications, CPR training, and professional liability.
  • Conduct required primary source verifications and searches (e.g., National Databank, SAM, OIG, NPI, etc.) for new and current providers and coordinate with human resources for completion of required criminal background checks. 
  • Identify opportunities to improve workflow, work processes and patient care and work cooperatively to implement those improvements.
  • Assist with the development and revision of relevant policies and procedures. 
  • Define and maintain responsibilities of the Health Center and the LPCACO as it relates to moving the credentialing process along, including updating Standard Operating Procedures (SOPs) as needed. 
  • Facilitate all relevant LPCACO governing bodies (i.e., Super User Credentialing Committee, Credentialing and Standards Committee, Provider Credentialing Committee) to process applications and make decisions about the growth of the program. 

Payor Enrollment and Credentialing
  • Lead the set-up of the payor enrollment module in CredentialStream to ensure Health Centers can effectively process and file applications with third party payors according to each payor’s requirements.
  • Develop and implement a strategy for obtaining and maintaining delegated credentialing agreements with payors. This includes identifying payors, initiating contact with the provider relations department of each payor, preparing applications according to each payor’s requirements, preparing for audits, negotiating agreements, and maintaining ongoing compliance and reporting. 
  • Ensure that health centers are able to maintain credentials with third party payors and that both practitioners and facilities are enrolled in Medicare/Medicaid.
  • Assist health centers in processing and filing applications with third party payors according to each payor’s individual requirements and addresses/corrects discrepancies and pending applications.
  • Prepare and maintain credentialing files and reports for all individual providers including maintenance of credentialing software, provider rosters and spreadsheets to comply with group delegation requirements, as required.
  • Accept and process all requests from payors for credentialing information/updates/new contracts and products. 
  • Answer questions, process requests from staff/providers related to credentialing information and provide support as needed in all aspects of the credentialing process.
  • Maintain provider’s CAQH profile by entering data, supporting documents, and re-attesting quarterly.
  • Complete Medicare and Medicaid revalidation applications in a timely manner to ensure all certifications are kept active and in good standing with CMS.
  • Work closely with the Network Director as well as health center revenue cycle management staff to respond to credentialing requests from commercial/private insurance companies and government agencies in a timely manner.
  • Adhere to HIPAA guidelines.
  • Any other duties as deemed necessary by supervisor. 
 Qualifications and Skills 
  • Bachelor’s degree. 
  • At least five years of credentialing experience. FQHC credentialing experience is a plus.
  • Certified Provider Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) Certification preferred.
  • Strong technical skills and database management skills. Experience with CredentialStream or other web-based credentialing software preferred. 
  • Working knowledge of applicable accreditation and regulatory standards (e.g., NCQA, URAC, etc.). 

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