Responsible for implementing, leading, coordinating, monitoring, and maintaining the enrollment, credentialing and re-credentialing process for established and onboarding groups and providersExecutes all aspects of unified women’s healthcare credentialing, including, primary source verification, and preemployment processes for all providers affiliated with unified women’s healthcareEnsures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialingResponsible for the accuracy and integrity of the credentialing database system, emr and related applicationsWorks under the supervision of the srNational director credentialing and provider services.
Essential duties and responsibilities:
Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibilityIncluding primary source verification through background investigationImplements the unified women’s healthcare credentialing, enrollment and preemployment process and policies.
Develops and executes existing and latest credentialing software, established and new credentialing processes and training for new and existing unified women’s healthcare staff on credentialing software and emr practitioner enrollment tables.
Credentialing and enrollment project lead for all new acquisitionsKey contact for related internal and external personnelCore contact for corporate implementation team.
Manages new acquisition credentialing and enrollment staff.
Manages workflow for all system or process implentationsFrom go live to follow up on completion.
Provides education and guidance to all levels on related steps to ensure a successful integration of initiatives.
Identifies scope of work through interviewing of key personnel.
Lead contact for department on all related implementation activities.
Maintain confidentiality of the provider information
Maintain knowledge of current health plan and agency requirements for credentialing and enrolling providers.
Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and enrollment issues as they arise.
Assists with managed care delegated credentialing audits; conducts internal file audits.
Utilizes the credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves national practitioner database reports in accordance with health care quality improvement act.
Utilizes and oversees the affiliates emr enrollment functions.
Monitors the initial, reappointment and expirables process for all medical staff, allied health professional staff, other health professional staff, and delegated providers, ensuring compliance with regulatory bodies (joint commission, ncqa, urac, cms, federal and state), rules and regulations, policies and procedures, and delegated contracts.
Performs miscellaneous job-related duties as assigned.
Qualifications and requirements:
Knowledge of credentialing and provider enrollment.
Knowledge of processes management.
Knowledge of emt enrollment functions.
Knowledge of related accreditation and certification requirements.
Ability to interact with tact and diplomacy with individuals from a variety of backgrounds and organizational levels.
Ability to use independent judgment to manage and impart confidential information.
Database management skills including querying, reporting, and document generation.
Ability to effectively communicate both in writing and verbally, as well as interact in a professional manner with colleagues (i.e., claim coordinators, account managers, and provider services), care centers staffing and the board.
Working knowledge of managed care operations and procedures.
Ability to work independently and make sound and timely decisions is a must.
Communicate effectively with all departments, client staff, and insurance contacts.
Demonstrated pc skill (i.e., highly proficient in microsoft office products including word and excel, project management, power point and outlook).
Familiar with the internet, able to do in-depth searches.
Ability to multi-task, excellent organizational skills and planning skills required.
Strong analytical and problem-solving skills.
Bachelor’s degree.
At least 5 years of experience with 3 years directly related to provider enrollment, credentialing or managed care preferred.
Bachelor’s degree in a related field (health care, business, finance, accounting or information systems, etc.) preferred.
Namss certification; preferred not required (cpcs or cpmsm).
Flexible work hours, if required depending on deadlines and events.
Travel, when required(10%-20% after covid)
