Location: all cities,TX, USA
Job Summary:
The Manager, Credentialing will oversee the credentialing function. This role will lead a team of analysts to provide guidance and oversight of credentialing new providers and maintaining current provider files for our quickly growing medical group. This hire will oversee the end-to-end credentialing process, including: submitting and tracking credentialing applications to various contracted managed care plans and government payors for oncoming providers; validating the accuracy of provider data loads in payor networks; maintaining accurate and updated data for all providers within the group; tracking the expiration of certification and licenses; support the markets with timely and accurate communications related to provider credentialing and provider data loads; and will act as a liaison between market leadership, payors, external credentialing service firms, and medical staff, including physicians.
Duties/Responsibilities:
▪ Evaluate and improve the credentialing workplan and processes, including all required credentialing for providers and facilities as dictated by government payors and contracted managed care plans
▪ Provide leadership and guidance to Credentialing Analysts
▪ Collaborate cross-functionally with Market Operations, Human Resources, Providers, and IT to ensure providers are credentialed and onboarded in a timely manner
▪ Oversee all necessary credentialing for providers and facilities, including:
o Conducting background checks
o Contacting licensing boards
o Reviewing license applications
o Obtaining education information
o Completing references
o Ensuring the facility is operating within state and federal regulations
▪ Regular status reporting to key stakeholders on credentialing and provider directory loads for providers
▪ Reconciliation and timely updates for payor provider data and provider directories to ensure that directories are accurate to support member empanelment required under risk contracts with payors.
▪ Own payor reporting, including data reporting and monthly exclusion checks
▪ Oversee ongoing renewals for all required physician licenses and credentials
▪ Act as a liaison between government payors and managed care plans, outsourced credentialing services, and medical staff, including physicians
▪ Additional duties as assigned
Required Skills/Abilities:
• Strong understanding of Medicare, Medicaid, and managed care plan credentialing requirements, plus familiarity with CAQH (Council for Affordable Quality Healthcare)
• Ability to build strong cross-functional relationships within an organization to drive projects and initiatives to completion
• Ability to partner and communicate with providers in a professional manner to assist in the completion of the CAQH applications
▪ Demonstrated track record of successfully executing in a high growth environment with limited infrastructure
▪ Strong organization and written communication skills
▪ Ability to communicate well with all levels of staff, providers, and patient referral sources
Education and Experience:
▪ Bachelor's degree preferred, or equivalent experience
▪ Minimum of five (5) years of relevant credentialing and enrollment experience, with at least two (3) years in a management role leading people
▪ Prior experience supporting credentialing of providers in a multi-site and multi-state healthcare delivery organization.
▪ Strong PC skills