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Compliance and Credentialing Specialist
4 months ago
The mission of the Boston Public Health Commission (BPHC) is to work in partnership with communities to protect and promote the health and well-being of all Boston residents, especially those impacted by racism and systemic inequities. The BPHC envisions a thriving Boston where all residents live healthy, fulfilling lives free of racism, poverty, violence, and other systems of oppression. The BPHC sets an expectation that all staff and leadership commit, individually and as part of the BPHC team, to hold ourselves accountable to establishing a culture of antiracism and advance racial equity and justice through each of our bureaus, programs, and offices
**DUTIES**
The Compliance and Credentialing Specialist reports to the Senior Revenue Analyst. This Compliance and Credentialing Specialist is responsible for designing and implementing a compliance program that enables BPHC to proactively adhere to regulatory requirements while also identifying and addressing potential regulatory issues that may arise. Compliance program activities include advisory, training, independent testing & monitoring, reporting, escalation, and oversight to the LCSW, LICSW, LADAC and other clinicians. The Specialist will be facilitating successful maintenance of Clinicians by performing ongoing monitoring processes of all required program clinicians in accordance with industry and contractual standards. The Specialist will communicate with outsourced vendors, healthcare facility points of contact / professionals, as well as internal staff to maintain a detailed and compliant practitioner file.
- Serves on the compliance and quality assurance leadership team of the Senior Revenue Analyst and Senior Leadership of the Substance Abuse Bureau for third party billing compliance.
- Coordinates written policies and procedures that set up standards for compliance, quality assurance and credentialing giving specific guidance to management, clinical professional staff, and individual departments as appropriate.
- Develops, implements, and maintains a system for efficient operations of the compliance, quality assurance and credentialing.
- Includes a communication tracking process for the credentialing and compliance program documentation and compliance committee projects and interactions.
- Develops, implements, and maintains a system for confidential reporting and investigation of compliance concerns with an appropriate response process allowing for anonymous compliance reporting.
- Coordinates with the Senior Revenue Analyst in response to identified compliance questions, quality assurance concerns, or federal/state inquiries or
- Directs efforts to communicate credentialing and compliance programs, including written materials and training programs designed specifically to promote understanding of compliance issues, laws and regulations, and consequences of non-compliance.
- Utilizes personal initiative, seminars, training programs, peer contacts, and various industry information resources (i.e., Internet sites, newsletters).
- Maintains a consistent management reporting process that provides the system with timely and relevant information on all aspects of compliance, quality assurance and credentialing issues.
- Reviews reported issues, concerns, or questions relative to compliance and credentialing matters.
- Provides consultative leadership and support to all entities as appropriate and all levels of management throughout the system. Coordinates the development, implementation, and maintenance of audit controls and measurements for internal processes; ensuring correct processes are in place for accurate, complete, and clinical compliance programs across the system.
- Uses independent judgment and discretion to make decisions affecting the program and staff as it relates to program operations/services and BPHC policy.
- Maintains a working knowledge of Medicaid Time Study for the Health Baby Health Child program and medical insurance as it relates to third party billing.
- Assists with Carelogic System as needed.
- Work to help BPHC become an antiracist organization by meeting or exceeding the standards set by the BPHC Anti-Racism Policy.
- Performs other duties as required.
**Minimum Qualifications**
**MINIMUM QUALIFICATIONS**
- Commitment to the promotion of health equity, inclusion, and diversity within BPHC and the community.
- Knowledge of or willingness to learn about the role of public health in addressing racism, the social determinants of health, and inequities in health outcomes as well as strategies to advance racial justice and health equity.
- BA/BS in Finance, Accounting, Business, Economics, or related field required or;
- Associate Degree in Finance, Accounting, Business, Economics, or related field and 2 years transferable Compliance and Credentialing experience or;
- 4 years of transferable Third-Party/Credentialing experience may be substituted in lieu of degree.
- Plus at least 2-3 years of transferable Third-Party e
