Credentialing Director

7 days ago

New York, New York, United States EmblemHealth Full time
Job Summary

We are seeking a highly skilled Credentialing Director to join our team at EmblemHealth. The successful candidate will be responsible for developing and implementing provider credentialing related policies, procedures, goals, and budget. This role requires a strong understanding of provider credentialing, related health plan processes, and DOH, CMS, and NCQA guidelines.

Key Responsibilities
  • Establish and maintain written credentialing related policies and procedures, ensuring compliance with federal, state, health plan, and NCQA regulations and guidelines.
  • Direct the credentialing and re-credentialing application process for AdvantageCare Physicians (ACPNY) and AdvantageCare Bronx, evaluating the credentials of all new providers joining ACPNY and AdvantageCare Bronx, and auditing files prepared by the credentialing specialists.
  • Prepare documents for review and present to ACPNY senior leadership at monthly credentialing meetings, managing the enrollment and revalidation of ACPNY and AdvantageCare Bronx providers in Medicare and Medicaid programs.
  • Ensure that group enrollment certifications are updated and current, directing day-to-day operations of the credentialing function, and maintaining appropriate staffing and productivity to meet targeted service levels, turnaround times, and satisfaction/quality levels.
  • Audit staff work to ensure that documentation is appropriate and stored in accordance with security and confidentiality protocols, ensuring initial and re-credentialing application files are maintained, and reviewing and evaluating all credentialing delegation contracts.
  • Manage all annual delegated credentialing audits, responding to audit requests, and reviewing monthly compliance reports to ensure providers are in good standing with all regulatory agencies.
  • Manage/monitor primary care physician member panel assignments, including the submission of panel changes to health plans as necessary, ensuring the departure and arrival dates of credentialed providers are tracked, and providing verification requests for providers who have left ACPNY.
  • Manage the credentialing vendor contract, overseeing the enrollment of providers with delegated health plans, reviewing weekly provider enrollment, and evaluating vendor performance.
  • Design and direct the use of the data fields in the credentialing database to ensure that appropriate information is captured to enable accurate reporting, developing provider reports for internal and external partners upon request.
Requirements
  • Bachelor's degree, Master's degree preferred (Health or Business Administration)
  • 10+ years' progressive related experience working with managed care organizations, inclusive of management experience
  • Strong understanding of provider credentialing, related health plan processes, and DOH, CMS, and NCQA guidelines
  • Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) and credentialing software
  • Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences
  • Strategic and tactical perspective on how to significantly improve operational performance
  • Ability to manage vendor line management and their respective staffs on a day-to-day basis
  • Experience using metrics to determine results; ability to implement and enforce SLAs (Service Level Agreements)
  • Knowledge of contracts/terminology to determine alignment of results to goals
  • Experience with outsourced processes and vendor management

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