Credentialing Manager

Job description

Summary: Medical Credentialing Manager – Delegation Team’s primary objective is to assist in the management of the Delegated Credentialing team and assist with the day-to-day operations of the Department

Essential Functions:

· Comply with Credentialing Policy and Procedures, Departmental Guidelines and Company Policy

· Prepare for monthly presentation of files to the Credentialing Committee meeting

· Ensure that all files are prepared correctly, and the team meets all deadlines set forth.

· Coordinate credentialing audits, in compliance with the managed care delegated credentialing contracts

· Submit each monthly roster by predetermined date, with accurate and complete data

· Coordinate with payors’ representatives to ensure timely receipt of participation

· Analyze participation received and ratify any gaps found

· Perform quarterly audits of complete provider rosters

· Delegate tasks to team members appropriately

· Train staff and ensure they fulfill the following responsibilities (include but not limited to):

o Review credentialing application for completeness, log and request missing documentation

o Critically evaluate application for any issues that may require special consideration, or additional review, and take appropriate action to resolve issue

o Perform primary source verification of license, DEA, Board Certification, NPDB, highest level of education, and other verifications.

o Delegate monthly monitoring of licensing boards, OPMC/license disciplinary summary, OMIG, OIG SAM and Opt-out, ensuring provider disciplinary actions are identified and addressed

o Monitor the initial appointment, re-appointment, ongoing monitoring and expiration process for all providers ensuring compliance with regulatory bodies (including but not limited to NCQA, CMS, Federal and State), as well as Essen Medical Credentialing policies and procedures, and delegated contracts

o Monitor and track responses from primary sources and send follow-up requests as needed until file is complete

o Notify Credentialing Manager of any quality issues regarding file, in a timely manner

o Respond to Credentialing Manager to provide status updates within one business day, from receipt of request

o Coordinate with appropriate credentialing onboarding staff to obtain required information from provider

o Prepare payment requests for required verification fees

o Participate in the timely preparation of files for the monthly Credentialing Committee meetings, Delegated Credentialing audits, on site audits and desktop audits

o Perform self-audit of work to ensure data integrity of provider files

o Identifies back-up coverage and the assignment of files when out of the office

o Document all tasks, phone calls, emails and other forms of communication during the credentialing/re-credentialing process.

o Collaborate with Billing/HR/Malpractice Departments

o Complete other tasks or projects as assigned

o Provide back-up to other Credentialing staff as necessary

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.

Education/ Work Experience:

· Bachelor’s Degree in a Health-Related Discipline: Public Health, Healthcare Administrative, Health Service, Psychology or Sociology Required

Experience:

· Mandatory provider credentialing experience (minimum of 1 -2 years), preferably in health care setting or within Hospital Medical Staff Department

Knowledge, Skills, Abilities and Other Characteristics:

· Strong interpersonal and communication skills with an ability to work effectively with a wide range of people, teams, managers, supervisors, and vendors.

· Proficient with MS Office (outlook, word, excel, power point, access)

· Excellent organizational and time-management skills.

· Excellent verbal and written communication skills.

· Knowledge of related accreditation and certification requirements.

· Knowledge of practitioner credentialing procedures and standards.

· Ability to analyze, interprets and draws inferences from research findings, and prepares reports.

· Working knowledge of clinical operations and procedures.

· Informational research skills.

· Ability to use independent judgment to manage and impart confidential information.

· Database management skills including querying, reporting, and document generation.

#CM200

Job Type: Full-time

Salary: $65,000.00 - $85,000.00 per year

Schedule:

• 8 hour shift
• Monday to Friday

Ability to commute/relocate:

• Bronx, NY 10457: Reliably commute or planning to relocate before starting work (Required)

Experience:

• Microsoft Office: 1 year (Preferred)
• Microsoft Word: 1 year (Preferred)

Will go over in interview

Salary : $65,000 - $85,000