Credentialing Manager #ESF9303

ExpertHiring•Philadelphia, PA

About The Position

What you will be doing: Lead, coordinate, and monitor the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility. Conduct thorough background investigations, research, and primary source verification of all components of the application file. Identify issues that require additional investigation and evaluation, validate discrepancies, and ensure appropriate follow-up. Prepare credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within specified time periods. Successfully complete and maintain initial and subsequent individual provider payor enrollments, i.e., Medicaid, Medicare, Commercial payors, CHIP, and other third-party insurance carriers. Process requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions. Maintain physical and electronic database of provider certifications, documents, expiration dates, and payor enrollment information. Respond to inquiries from other healthcare organizations and interface with internal and external customers on day-to-day credentialing and privileging issues. Assist with managed care delegated credentialing audits and conduct internal file audits. Monitor the initial, reappointment, and expirable process for all SHS Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies and organizational policies. Perform miscellaneous job-related duties as assigned. Maintain a proactive working knowledge of all clinical service lines relative to the credentialing process. Establish goals and develop training processes to ensure maximization of technical support available. Analyze credentialing reporting using the Med-Trainer platform and internally maintained spreadsheets. Collaborate with the Revenue Cycle Director and Revenue Cycle Manager to maintain all payor rosters. Work in partnership with the Human Resources Department to optimize provider documentation collection. Establish quality review processes to ensure the effectiveness of the credentialing process and make modifications as needed. Ensure areas of responsibility achieve quarterly and annual goals and other established KPIs. Comply with federal and state laws, and SHS policies and procedures related to revenue cycle management.

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 is a plus.

Responsibilities

Lead, coordinate, and monitor the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
Conduct thorough background investigations, research, and primary source verification of all components of the application file.
Identify issues that require additional investigation and evaluation, validate discrepancies, and ensure appropriate follow-up.
Prepare credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within specified time periods.
Successfully complete and maintain initial and subsequent individual provider payor enrollments, i.e., Medicaid, Medicare, Commercial payors, CHIP, and other third-party insurance carriers.
Process requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
Maintain physical and electronic database of provider certifications, documents, expiration dates, and payor enrollment information.
Respond to inquiries from other healthcare organizations and interface with internal and external customers on day-to-day credentialing and privileging issues.
Assist with managed care delegated credentialing audits and conduct internal file audits.
Monitor the initial, reappointment, and expirable process for all SHS Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies and organizational policies.
Perform miscellaneous job-related duties as assigned.
Maintain a proactive working knowledge of all clinical service lines relative to the credentialing process.
Establish goals and develop training processes to ensure maximization of technical support available.
Analyze credentialing reporting using the Med-Trainer platform and internally maintained spreadsheets.
Collaborate with the Revenue Cycle Director and Revenue Cycle Manager to maintain all payor rosters.
Work in partnership with the Human Resources Department to optimize provider documentation collection.
Establish quality review processes to ensure the effectiveness of the credentialing process and make modifications as needed.
Ensure areas of responsibility achieve quarterly and annual goals and other established KPIs.
Comply with federal and state laws, and SHS policies and procedures related to revenue cycle management.