| The Director of Credentialing will oversee credentialing/privileging program to assure credentialing processes are in compliance with professional standards and state/federal regulatory requirements; health plan delegation for credentialing is maintained, and corporate growth initiatives are supported. The individual and team play a key role in linking operations and systems to ensure these functions are in sync with strategic initiatives. Essential Functions: - Maintains knowledge of all NCQA standards for Managed Care Organizations, Credentials Verification Organizations, and JCAHO standards for Ambulatory Care. Serves as a resource to Credentials Analysts, Credentials Committee and to Cenevia Network Members and clients on credentialing topics.
- Develops and maintains credentialing policies and procedures to assure compliance with applicable standards, including the Cenevia Credentials Program Description. Assures annual review and/or revision of same.
- Coordinates and Implements efficient Credentialing and Provider Enrollment activity between payers while ensuring providers are participating with the payers in a timely and accurate manner. Provides timely updates to shareholders/clients. This includes inter department coordination to facilitate billing activity.
- Engages Contracting & Enrollment teams to achieve departmental and strategic goals; prioritizes responsibilities and objectives so goals may be accomplished.
- Develops and trains team members on contracting and enrollment best practices and identifying process improvement opportunities as well as recommended system enhancements.
- Contributes discretionary effort to strategic initiatives and priorities.
- Develops and ensures metrics, goals, and projects are documented, executed, tracked, and accomplished.
- Works with Marketing Director to grow client base, service offerings, and increase credentialing and enrollment revenue stream.
- Directs the supervision of personnel, which includes work allocation, training, enforcement of internal procedures and controls, and problem resolution.
- Evaluates performance and makes recommendations for personnel actions.
- Oversees the data integrity and functionality of credentialing and enrollment databases; generates reports and prepares audits as requested.
- Shares customer feedback and uses that feedback to establish value added business processes.
- Facilitates the implementation of credentialing committee recommendations and follow-through.
- Oversees the notification to health plans of provider terminations and reassignment of membership when applicable.
- Oversee the notification to health plans of provider information/demographical updates and changes as well as practitioner panel changes.
- Responsible for monthly, quarterly, and semi-annual reporting of credentialing activities to health plans.
QUALIFICATIONS: - Bachelor’s degree in Science or health care related field.
- CPCS Certification.
- At least 5 years of leadership experience in credentialing.
- Working knowledge of the health care and credentialing industry, regulatory agencies, and other national standards.
- Understanding of the credentialing and privileging processes for hospitals and ambulatory care settings.
- Advanced knowledge of medical terminology.
- Expert knowledge of JC and NCQA standards, as well as federal and state regulations with regard to medical staff credentialing.
- Experience with database management.
COMPETENCIES: - Business Acumen - Understands the impact of credentialing and privileging and provider enrollment functions on the organization’s strategy and goals.
- Client Focus - Anticipating, understanding, and fulfilling customer needs and expectations by providing excellent direct and indirect service.
- Communication - Demonstrates openness, honesty, and transparency in all interactions. Speaks, listens, conveys, and shares ideas in a clear, logical and successful manner.
- Initiative - Seeking new/additional responsibilities, projects, tasks; Acting independently in new/routine situations.
- Managing People - Includes staff in planning, decision-making, facilitating and process improvement; takes responsibility for subordinates' activities; makes self-available to staff; provides regular performance feedback; develops subordinates' skills and encourages growth; solicits and applies customer feedback (internal and external); fosters quality focus in others; improves processes, products, and services; continually works to improve supervisory skills.
PHYSICAL DEMANDS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to stand and walk. The employee must occasionally lift and/or move up to 10 pounds. Specific vision abilities required by this job include close vision, distance vision, color vision, peripheral vision, depth perception and ability to adjust focus. WORK ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate. Cenevia is an equal opportunity employer. At Cenevia, we believe diversity brings strength and adaptability by drawing on a broad range of talents, experiences and perspectives, and affords an inclusive workplace and culture where all people, regardless of gender, race, ethnicity, sexual orientation, or background, feel a sense of belonging. This position is remote, and employee must have suitable and secure technology to be eligible for consideration – e.g., secure Wi-Fi, telephone, dedicated workspace. Additionally, employee is required to participate and be seen in meetings via video conference as part of this role. |
