Manager Provider Credentialing

ESSENTIAL JOB DUTIES/RESPONSIBILITIES:

• Manages physician/provider credentialing service delivery including scope, resources and timelines.
• Sets customer expectations in accordance with agreed upon terms and conditions.
• Serves as the primary point of contact for payor related questions, issues and requests which includes but is not limited to:
  • Provider participation status
  • Primary location confirmation
  • Audits finding and remediation to align directories
  • Receives and addresses warning and escalation notices due to non-compliance
  • Provides monthly rosters of active providers by market
  • Addresses escalations on enrollment barriers, misses/gaps
  • Develops and maintains strong business relationships with payors to ensure smooth and seamless process
  • Receives and distributes information related to enrollment changes
• Serves as the primary point of contact for market related questions, issues and requests, including but not limited to:
  • Resolve/addresses escalations from payors that go directly to the centers
  • Resolve/addresses escalations by helping validate PAR status due to encounter rejections
  • Coordinates Medicare and Medicaid needs with provider enrollment vendor
  • Works with HR Ambassadors to ensure enrollment/credentialing dependent processes such as location changes and terminations are being followed
  • Ensures provider profile integrity in Workday
• Builds knowledge resources and conducts training of key stakeholders to make certain process standards are applied and adhered to. As the subject matter expert (SME), ensures process and procedure knowledge is harnessed and utilized to help consistently improve the credentialing experience with payors.
• Supports New Market builds by:
  • Participating in credentialing-related market meetings
  • Providing SME knowledge to new market teams on credentialing dependencies
  • Working with new payors to understand points of contacts for credentialing
  • Introducing credentialing vendor and ensuring they understand the enrollment process
  • Providing initial PAR roster for setup and coordinating with the HR Ambassador Manager to ensure new physicians/providers are timely submitted to credentialing vendor
  • Ensuring providers are PAR for the initial setup and payor provides necessary data to update credentialing portal
  • Ensuring credentialing portal is updated and accurate
• Creates and executes a project plan and works with key stakeholders to ensure ChenMed has delegated credentialing with payers.
• Co-creates polices and processes needed to get delegated credentialing.
• Coordinates and facilitates meetings and committees required for delegated credentialing.
• Ensures organization stays current and adheres to policies, procedures and guidelines for delegated credentialing
• Manages the provider enrollment vendor to confirm they are delivering against SLA and course correct to alleviate barriers and/or issues. Provides regular feedback and follow-up to leadership regarding the contract process, status and approval of hospitals and provider.
• Partners with legal to maintain awareness of payor terminations and guarantee proper downstream stakeholders are informed and upholding the integrity of their processes (i.e. removing payors from enrolling providers in the future).
• Reviews CMS website to verify PECOS (Medicare) enrollments are current and holds third party provider enrollment vendor accountable for renewals and follow-ups.
• Collaborates with market leaders to make sure centers are adhering to location change and termination processes and procedures. Ensuring that location changes are submitted at least 30 days before the move and terminations are submitted at least 90 days prior to last day of work.
• Evaluates credentialing ecosystem to explore opportunities for process and business improvements.
• Provides recommendations on how to improve the data submission process to guarantee accurate and appropriate enrollment to payers.
• Researches and recommends third party providers enrollment companies that can enhance and evolve ChenMed’s enrollment services and technology.
• Analyzes and suggests ways to improve market self-sufficiency and encourage independence in the credentialing process.
• Oversees facility credentialing through NPPES, PECOS, NPI.
• Performs other duties as assigned and modified at manager’s discretion.

KNOWLEDGE, SKILLS AND ABILITIES:

• High business acumen and acuity
• Expert knowledge of Multi-state Medicare, Medicaid and commercial payor enrollment requirements
• Advanced knowledge of physician/provider credentialing requirement
• Understands delegated credentialing requirements from payors
• Experience working in CAQH, Medicare and Payer enrollment systems
• Ability to lead projects and organize and lead multi-disciplinary project teams through associated project activities
• Ability to influence all levels of organizational leadership to help drive process, strategy and adherence to proper business protocols
• Excellent oral and written communication skills and effectively and diplomatically communicates with internal and external customers and employees
• Excellent follow-through; assumes responsibility and uses good judgment
• Prioritizes workload and maintains a professional attitude even in stressful situations
• Has a proven track record of success and can demonstrate progressive responsibility
• Detail-oriented with exceptional organization skills
• Inspired to go above and beyond to achieve exceptional results; a real problem-solver
• Enthusiastic and motivated to excel in a company that recognizes and rewards capability, growth, initiative and drive
• Self-motivated and skilled at working independently or equally as well with a team
• Ability to effectively prioritize and manage multiple daily/weekly tasks
• Proficient in Microsoft Office Suite products including Word, Excel, PowerPoint and Outlook, plus a variety of other word-processing, spreadsheet, database, e-mail and presentation software
• Ability and willingness to travel locally, regionally and nationwide up to 10% of the time
• Spoken and written fluency in English
• This job requires use and exercise of independent judgment

EDUCATION AND EXPERIENCE CRITERIA:

• Bachelor degree in Health Services Administration or a closely related field OR additional experience above the minimum will be considered in lieu of the required education on a year-for-year basis required
• A minimum of 3 years’ Project Management experience required, preferably in the Healthcare industry
• A minimum of 3 years’ work experience in credentialing and/or provider enrollment; actual billing experience a plus
• A minimum of 3 years’ experience working directly or indirectly with healthcare systems
• Experience working in CAQH and Medicare preferred