Credentialing Manager

Rogers Memorial Hospital•Oconomowoc, WI

About The Position

The Credentialing Manager is primarily responsible for oversight of all activities impacting facility and practitioner external provider enrollment and credentialing; this includes all network application and maintenance processes that impact facilities and medical staff providers employed or contracted by Rogers Memorial Hospital, Inc. In all activities, the Credentialing Manager must remain aware of and comply with legal, regulatory, and financial policies and procedures. The Credentialing Manager is in regular contact with teammates, medical office staff, financial services staff, physicians/ practitioners, and healthcare contracting administrators. The Credentialing Manager works independently and reports to the Vice President of Payer Strategies. The Credentialing Manager frequently coordinates and works directly with multiple team(s) and members, and with leadership both within and outside of the organization including but not limited to CEOs, CFOs, VPs, and Directors.

Requirements

Bachelor’s degree
7 year credentialing and management experience
Administrative skills, including computer/word processing
Computer proficiency, adaptability and working knowledge of Microsoft Office, Adobe and Excel
Exceptional critical thinking skills and sound judgement
Exceptional written, verbal, and auditory skillset
Ability to perform all essential job functions either on site or remotely

Nice To Haves

Working knowledge of credentialing accreditation regulations, policies and procedures, and NCQA standards
General understanding of health insurance plans, provider enrollment processes, payer contracting and remittance processes, and HIPAA and healthcare compliance
Familiarity with practitioner billing and claims payment system requirements as related to practitioner enrollment
Symplr Experience
Experience with CAQH (Council for Affordable Quality Healthcare) database and application process
Prior professional history in a medical or mental health setting
CPCS Certification

Responsibilities

Facility and Practitioner Credentialing Activities Maintain understanding of RBH Privacy Practices, HIPAA, Medical Staff standards, state and federal requirements, and other applicable corporate and departmental policies.
Responsible for educating new staff regarding processes, regulations, and/or requirements pertinent to credentialing applications
Responsible for facility and practitioner enrollment activities, maintaining up to date file information in multiple systems, answering inquiries related to network status, collaborating with colleagues to ensure accuracy of facility contracted networks and affiliations.
Create, administer, and interpret policies and procedures related to payer enrollment
Serves as subject matter expert in the credentialing support software system environment, providing insight(s) and completing updates that increase environment efficiency
Responsible for making modifications in credentialing software systems to support evolving workflows, coordinating closely with the technical resource(s) and/or vendors responsible for building and maintaining the software
Implement policy and procedural updates as applicable
Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact credentialing, enrollment, and/or remittance activities
Create and maintain standard outreach to on-boarding medical staff providers detailing initial and ongoing provider enrollment requirements
Maintain knowledge of all data and document locations required as part of the enrollment process
Develop and maintain standard work detailing contracted payer provider credentialing processes for all exclusive contracts.
Maintain accurate RBH location and demographic information
Maintain list of contracted payers and status (inclusive/exclusive) by state
Populate and maintain both facility and provider level information in the CAQH system
Enroll and maintain practitioner affiliation in all appropriate contracted health plans
Enroll practitioners with government payers using electronic application methods such as PECOS and portals
Populate credentialing software with timely and accurate provider status and affiliation information
Monitor and disseminate affiliation, application and revalidation status upon request and as applicable
Maintain privacy and confidentiality at all times.
Payer Strategies _ Internal Establish and maintain positive and cooperative working relationship with other team professionals
Coordinate with and function as liaison between Payer Strategies, PFS, Medical Staff Office, Revenue Integrity, and other applicable stakeholders
Remain aware of contractual adjustments that may impact provider affiliations and/or payment
Complete regular and pro-active review of contracting payer reference table(s)
Review and respond to contracting department notice(s) and tickets Patient Financial Services and Medical Staff Office _ Internal
Establish and maintain positive and cooperative working relationship with all Patient Financial Services and Medical Staff Office team professionals
Assist Managers and Directors with facility level taxonomy/specialty updates and investigations
Maintain responsibility for Symplr Provider PFS portal development and staff trainings
Populate and maintain Symplr Provider information referenced by PFS staff to investigate and appeal professional claim denials
Establish and provide ongoing assist with PFS staff Symplr Provider logins
Assist department managers with WI Medicaid portal, including establishing clerk access and completing password resets upon request Contracted Payer Groups _ External
Regular written and verbal communications with payer group representatives at multiple levels
Respond to all payer outreach for information and/or clarification Other Duties and Responsibilities
Provide Executive and/or other support with state and contracted payer portal(s)
Complete projects as assigned by Vice President of Payer Strategies
Regular assistance with and dissemination of payer communications impacting other departments
Participate in process improvement events and activities
Serve as a back-up to other Medical Staff Services positions on an as-needed basis.
Assist in promoting a team atmosphere by treating individuals with respect and honesty and by using direct communication and active listening skills.