Provider Network Credentialing Manager

Job Details Description Curana Health is a provider of value-based primary care services for the senior living industry, including skilled nursing facilities, assisted & independent living communities, Memory Care units, and affordable senior housing sites. Our 1,000+ clinicians serve more than1,500 senior living community partners across 33 states, and Curana participates in various innovative CMS programs (including owned-and-operated Accountable Care Organizations and Medicare Advantage plans). With rapid year-over-year growth since our founding in 2021, Curana is setting a new standard in innovative care delivery for seniors with high-risk, complex clinical needs, many of whom have been historically underserved by the health care system. Our mission: To radically improve the health, happiness and dignity of senior living residents. Curana Health is looking for a qualified candidate to lead our Credentialing process, as a Provider Network Credentialing Manager. This role reports to the Director of Provider Network Management. Job Summary: This role will oversee all aspects of the credentialing process according to CMS, NCQA, state and insurance standards. This role is a critical part of Curana's operations and essential to our ability to onboard providers, as well as our ability to expand our services to new geographical service areas. Utilize your expertise and ideas to shape the department and implement new processes as the team and organization expands. Responsibilities: Monitoring and Management of Credentialing Vendor Organization (CVO) performance to contracted standards. Oversee CVO Queue Management, Provider File Maintenance, Quality, Production and Timeliness of credentialing standards are met. Define and support the development and maintenance of the AAH Provider Network Credentialing Policies and Procedures – ensuring required process implementation and operational performance to defined methods and standards. Keep management, plan Executive Directors and Account Managers informed of department issues, stakeholder failure to follow defined procedures and submission standards in work submitted, quality of vendor work and systems performance and recommended efficiencies to improve cost effectiveness, timeliness, and quality. Work with vendors, peers and AAH management in enforcing a systematic approach to credentialing workflow. Make and oversee credentialing system updates ensuring provider contracted and credentialing status is properly reflected in the Provider Data Management tool, Provider360. Provide monthly written assessment of vendor performance based on defined, objective criteria. Ensure provider, facility and delegated entity credentialing approval, denial, follow up and request letters are tracked, generated, and delivered timely for distribution. Monitor the Provider Data Management system and CVO processing system integration, implementation, and operations, assisting the data team with information and process updates as needed. Research provider credentialing issues and implement new processes to prevent re-occurrence. Maintain Credentialing Committee documentation, present provider issues at committee and oversee the committee agenda. Oversee delegation standards, ensure delegated groups maintain compliance and notify impacted areas of delegation approvals/denials. Communicate delegation & credentialing status to providers and ensure proper updates are made to the provider management system. Review CVO monitoring, outreach, credentialing, and failure reports on an ongoing basis, ensuring proper communication is sent to providers as well as impacted business areas when a provider’s credentialing status changes. Perform email, written and verbal outreach to providers to obtain missing or updated documentation needed for credentialing or recredentialing of providers. Review and transmit weekly facility & physician credentialing applications to CVO and perform QA on outgoing and incoming files to ensure all providers are successfully transmitted to the CVO platform. Train new AAH staff, Medical Directors, and plan partners on AAHs credentialing process and the CVO platform as needed. Knowledge & Skills Required: Minimum 7 years within a Managed Care environment and payor organization Bachelor’s Degree or an equivalent combination of education and/ or healthcare experience Minimum of 5 years with provider contracting and credentialing processes. Comprehensive understanding of facility and physician credentialing requirements as published by CMS and State Medicaid agencies, where applicable Experience of performance managing 3rd party vendor partners. Excellent communication skills and ability to engage at all levels of an organization and with client partners. Microsoft Office Suite Curana Health is dedicated to the principles of Equal Employment Opportunity. We affirm, in policy and practice, our commitment to diversity. We do not discriminate on the basis of actual or perceived race, color, creed, religion, national origin, ancestry, citizenship status, age, sex or gender (including pregnancy, childbirth and related medical conditions), gender identity or gender expression (including transgender status), sexual orientation, marital status, military service and veteran status, physical or mental disability, protected medical condition as defined by applicable or state law, genetic information, or any other characteristic protected by applicable federal, state and local laws and ordinances. The EEO policy applies to all personnel matters as outlined in our company policy including recruitment, hiring, transfers, and general treatment during employment.