Credentialing Manager - Remote position (MUST reside in Texas)

Purpose of the position

The Credentialing Manager is responsible for overseeing all aspects of credentialing and recredentialing of health care professionals. This position ensures all health care professionals are appropriately credentialed, which includes the responsibility of maintaining current information on file and within credentialing databases. The Manager is integral to OLS maintaining our delegated credentialing responsibilities.

MANAGER-SPECIFIC RESPONSIBLITIES:
? Deep understanding of the National Committee on Quality Assurance (NCQA) standards and State and Federal regulations related to credentialing. Maintain policies and procedures for the department that are consistent with standards and best practices therein.
? Responsible for hiring, training, and performance management of assigned personnel. Inspire team to continually learn, improve processes, cross-train and help one another.
? Manage delegated credentialing agreements, annual audits and communications with payers.
? System administrator for the Credentialing database, including maintenance of workflow settings, user permissions, standard processes, contracts. Ensure data is valid, current and free of errors. Work with VP to maximize the use of database for internal department, RCM and Division efficiency, including reporting, appropriate user security, and updating with new functionality.
? Emphasize prioritization and urgency related to the onboarding of new providers and monitor progress along established predictive timelines.
? Responsible for monitoring and managing credentialing/re-credentialing requirements with payers and facilities. Ensure Credentialing database is up to date with the most current forms to facilitate the efficient onboarding of providers. Report status monthly to Divisions.
? Ensure processes are in place for license and other certification renewals in advance of expiration consistent with the timeline set forth by the Quality & Compliance Committee. Report status monthly to Divisions.
? Accountable for Department budget and expense reporting, including managing personnel expense & overtime, equipment & office supplies, employee appreciation, license expenditures & credentialing fees. Obtain approval prior to purchase for non-budgeted expenses.
? Responsible for compliance with regulations related to roster maintenance, including performance of roster review on payer portals, providing current rosters to payers and validating rosters received from payers.
? Prepare initial application summary and submit clean records to Quality & Compliance Committee chairman. Any red flag records will be presented to the Quality & Compliance committee.
? Answer credentialing inquiries and provide support to physicians, physician office staff, health plan contacts and company departments as necessary.
? Audit Texas Disciplinary reports, OIG reports, and other reports as required and alert VP when applicable.
? Ability to support all credentialing operations (providing back-up support for telephones, credentialing files, and vacation/PTO).
? Participate in various educational/training as required. Perform other related duties as assigned.
? Comply with HIPAA and Corporate Compliance program policies and other applicable corporate and departmental policies.
? Maintain privacy and confidentiality at all times.

OVERSEE THE FOLLOWING RESPONSIBLITIES DELEGATED AND PERFORMED BY THE CREDENTIALING STAFF:
? Completion of health care professionals credentialing and re-credentialing applications.
? Data entry of new applications in the credentialing database.
? Perform and collect PSV (primary source verification) documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on NCQA standards, health plan requirements and company credentialing policies.
? Maintain the credentialing database, CAQH profiles, NPPES, and TXCOMP, always ensuring up-to-date information. Responsible for monitoring and managing credentialing/re-credentialing requirements and to ensure the collection of all required renewal certifications are on file on time.
? Provide consistent and timely follow-up on all outstanding credentialing/re-credentialing files.
? Prepare and scan credentialing/re-credentialing files and other credentialing documentation into scanning software.
? Process provider demographic changes ensuring appropriate documentation has been submitted with the changes, update credentialing database and notify health plans of changes.
? Process provider network terminations, specialty/category changes, leave of absence requests.

Qualifications
? Bachelors Degree required.
? Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) certification or progress toward these certifications is required.
? Minimum of three (3) years of supervisory or management level experience in a healthcare organization, including credentialing oversight.
? Five (5) or more years credentialing experience preferred.
? Experience with CAQH (Council for Affordable Quality Healthcare) database and applications.
? Working knowledge of credentialing accreditation regulations, policies and procedures, and NCQA standards.

Performance Skills
? Must be fluent in Microsoft Office 365 applications and have advanced Excel skills.
? Database administration background, including users, table management, reporting.
? Must demonstrate exceptional communication skills, listening effectively and asking questions when clarification is needed.
? Ability to plan, assign, supervise and evaluate the work of others, and to monitor goals, objectives, deadlines and priorities.
? Demonstrate accuracy, organizational and problem-solving skills. Look for ways to improve and promote quality and monitors own work to ensure quality is met.
? Maintain confidentiality.
? Ability to assume responsibility and exercise good judgement in making decisions within the scope of authority of the position.
? Must demonstrate and promote a positive team-oriented environment.
? Must be able to stay focused and concentrate under normal or heavy distractions.
? Must possess ability to manage change, delays, or unexpected events appropriately.

Disclaimer The above statements are intended to describe the general nature and level of work being performed by people assigned to this classification. They are not construed as an exhaustive list of all responsibilities, duties and skills required of personnel so classified. All personnel may be required to perform duties outside of their normal responsibilities from time to time, as needed.

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