Credentialing Manager

Spectrum Health Services•Philadelphia, PA

46d

About The Position

Essential Functions: Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility. Conducts thorough background investigation, research, and primary source verification of all components of the application file. Identifies issues that require additional investigation and evaluation, validates discrepancies, and ensures appropriate follow up. Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within time periods specified. Successfully completing and maintaining initial and subsequent individual provider payor enrollments, i.e., Medicaid, Medicare, Commercial payors, CHIP, & other third-party insurance carriers. Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions. Maintains physical and electronic data base of provider certifications, documents, expiration dates, and payor enrollment information. Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise. Assists with managed care delegated credentialing audits; conducts internal file audits. Monitors the initial, reappointment and expirable process for all SHS Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (HRSA, CMS, federal and state), as well as Rules and Regulations, policies and procedures, and delegated contracts. Performs miscellaneous job-related duties as assigned. Maintains a proactive working knowledge of all clinical service lines relative to the credentialing process. Establishes goals and develops training processes to ensure maximization of technical support available. Analyzes credentialing reporting using the Med-Trainer platform and internally maintained spreadsheets. Collaborates with Revenue Cycle Director and Revenue Cycle Manager to maintain to all payor rosters. Work in partnership with Human Resources Department to optimize provider documentation collection. Establishes quality review processes to ensure the effectiveness of the credentialing process and make modifications as needed. Ensures areas of responsibility achieve quarterly and annual goals and other established KPI's. Complies with federal and state laws, SHS policies and procedures related to revenue cycle management. This position does not supervise others

Requirements

High school diploma or GED; at least 6 years of experience with 4 years directly related to health center medical staff or managed care credentialing.
Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.
Ability to communicate effectively, both orally and in writing.
Knowledge of related accreditation and certification requirements.
Knowledge of medical credentialing and privileging procedures and standards.
Ability to analyze, interpret and draw inferences from research findings, and prepare reports.
Working knowledge of clinical and/or hospital operations and procedures.
Ability to use independent judgment to manage and impart confidential information.
Database management skills including querying, reporting, and document generation.
Ability to make administrative/procedural decisions and judgments.

Nice To Haves

Non-profit experience preferred
Federally Qualified Health Center work experience a plus

Responsibilities

Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
Conducts thorough background investigation, research, and primary source verification of all components of the application file.
Identifies issues that require additional investigation and evaluation, validates discrepancies, and ensures appropriate follow up.
Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within time periods specified.
Successfully completing and maintaining initial and subsequent individual provider payor enrollments, i.e., Medicaid, Medicare, Commercial payors, CHIP, & other third-party insurance carriers.
Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
Maintains physical and electronic data base of provider certifications, documents, expiration dates, and payor enrollment information.
Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
Assists with managed care delegated credentialing audits; conducts internal file audits.
Monitors the initial, reappointment and expirable process for all SHS Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (HRSA, CMS, federal and state), as well as Rules and Regulations, policies and procedures, and delegated contracts.
Performs miscellaneous job-related duties as assigned.
Maintains a proactive working knowledge of all clinical service lines relative to the credentialing process.
Establishes goals and develops training processes to ensure maximization of technical support available.
Analyzes credentialing reporting using the Med-Trainer platform and internally maintained spreadsheets.
Collaborates with Revenue Cycle Director and Revenue Cycle Manager to maintain to all payor rosters.
Work in partnership with Human Resources Department to optimize provider documentation collection.
Establishes quality review processes to ensure the effectiveness of the credentialing process and make modifications as needed.
Ensures areas of responsibility achieve quarterly and annual goals and other established KPI's.
Complies with federal and state laws, SHS policies and procedures related to revenue cycle management.