Credentialing Manager

2 days ago

Edgewood, Maryland, United States Commonwealthorthocenters Full time
Credentialing Manager Job Summary

At Commonwealth OrthoCenters, we are seeking a highly skilled Credentialing Manager to oversee and monitor the activities of our Credentialing Department. This role is responsible for ensuring that all medical providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities.

Key Responsibilities:
  • Oversight of all activities and staff of the department
  • Actively participates in all functions of the department
  • Responsible for ensuring providers are credentialed, appointed, and privileged with health plans, hospitals, and patient care facilities
  • Recognizes, investigates, and validates discrepancies and potentially adverse information received from applications, primary sources, or other sources
  • Develops a standardized system for effective management of providers and plans
  • Maintains up-to-date data and accurate data for each provider in credentialing databases and online systems
  • Establishes and maintains up-to-date information in CAQH/PECOS profiles for new and existing providers
  • Utilizes software functions to convert paper documents to electronic files where possible
  • Completes provider credentialing and re-credentialing applications while monitoring applications and follows-up as needed
  • Ensures updates are completed in a timely manner to avoid deactivations
  • Maintains copies of current state licenses, DEA certificates, malpractice coverage, and any other required credentialing documents for all providers
  • Initiates requests for new contracts with payers as needed
  • Maintains corporate provider contract files
  • Assists billing department with monitoring charge review and claim denials when a credentialing issue is identified
  • Establishes and maintains effective working relationships with other departments, staff, managers, and providers
  • Disseminates information of credentialing process as appropriate
  • Maintains knowledge of current health plan and agency requirements for credentialing providers
  • Ensures practice addresses are current with health plans, agencies, and other entities
  • Audits health plan directories for current and accurate provider information
  • Maintains confidentiality of provider information
  • Provides credentialing and privileging verification
  • Follows HIPAA regulations
  • Takes initiative in performing additional tasks that may be necessary or in the best interest of the Practice
Requirements:
  • Education/Experience: High School Diploma or equivalent. Associate's Degree preferred. Certification and/or licensure: Certified Provider Credentialing Specialist (CPCS) preferred. Minimum two years relevant credentialing management experience
  • Other Requirements: In-house, full-time position. Schedules will change as department needs change, including overtime and weekends

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