Credentialing Program Manager

OhioHealth • Marion, OH

80d

About The Position

The Credentialing Program Manager reports to the Medical Affairs Manager and/or Director. The primary purpose of the position is to direct, monitor and provide quality credentialing/privileging and re-credentialing/privileging processes to ensure that physicians and allied health practitioners meet applicable accrediting, legal, and regulatory standards. This Credentialing Program Manager identifies and assesses areas of compliance according to TJC, ODH, CMS and other accreditation agencies. The Credentialing Program Manager serves as the content expert as it pertains to the credentialing process and responds to any inquiries regarding the credentialing/re-credentialing process from providers, hospitals, outside agencies/institutions, and other entities. In addition to medical providers, this individual interacts with medical staff office(s), quality management, compliance, medical staff and hospital leadership, and other professionals as necessary to ensure the integrity of the credentialing process. The Credentialing Program Manager is responsible for a systematic, disciplined approach to ensure provider data accuracy and integrity, and independently investigates and validates information to report trends. Leads process improvement activities to ensure operating efficiencies of the credentialing process. This Credentialing Program Manager works directly with medical staff leadership regarding discrepancies identified in provider applications and may act as a liaison to state medical licensure boards. The Credentialing Program Manager works independently under general supervision with considerable latitude for initiative and independent judgement.

Requirements

• Bachelor's Degree (Required)
• Two years' experience in the healthcare, managed care, credentialing or medical staff services field or equivalent combination of education and 7+ years' experience in healthcare, managed care, credentialing or medical staff services field.
• Knowledge of physician and allied practitioner credentialing processes.
• Detailed understanding of TJC, ODH, and CMS credentialing requirements.
• Strong communication skills, both written and oral.
• Strong organizational skills and attention to detail.
• Credentialing database management (Cactus or similar credentialing database).
• Team/associate accountability and conflict resolution.
• Excellent interpersonal and customer services skills.
• Critical thinking and problem solving skills.

Nice To Haves

• Certification as a Provider Credentialing Specialist (CPCS) or Medical Staff Coordinator (CMSC) preferred.

Responsibilities

• Conduct, participate in, and maintain credentialing and privileging.
• Complete evaluation of a credentialing application to determine applicant's initial eligibility for privileges.
• Analyze application and supporting documents for completeness.
• Verify and document expirable using acceptable verification sources to ensure compliance with accreditation and regulatory standards.
• Perform detailed and thorough review of applications, primary source verifications, and sources provided.
• Independently investigate and validate the information and escalate findings as needed.
• Recognize potential discrepancies and adverse information, and independently investigate and validate information in applications, primary source verifications, or other sources.
• Determine the applicant's initial eligibility for privileges based on approved criteria.
• Compile, evaluate and present the practitioner-specific data collected for review by one or more decision-making bodies.
• Serve as the main point of contact for the practitioner during the application process, providing timely updates and additional information as requested.
• Manage the credentialing, recredentialing and privileging process.
• Uniformly apply clearly defined credentialing/privileging processes to all practitioners.
• Evaluate credentialing/privileging requests and evidence of education, training, and experience to determine eligibility for requested privileges.
• Comply with internal and external requirements related to verifying the status of all practitioner expirables (e.g. licenses, certifications) by querying approved sources and recommending actions to ensure compliance.
• Complete quality review of all completed appointment/reappointment files which includes, file audit check list completion, all supporting documentation, all query requirements, and file organization.
• Facilitate the review of Physician and Allied Health Practitioner credentialing files.
• Participate on Physician Credentials Committee and/or Allied Health Practitioner Committee by compiling and presenting related materials for committee action and prepares report for the Medical Executive Committee and Board of Trustees for final approval.
• Serve as liaison with clinical departments for the purpose of medical staff credentialing and privileging and collaborate with managers and directors of other hospital departments to ensure that Physicians and Allied Health Practitioners are only performing procedures for which they are privileged.
• Conduct, participate in, and maintain current clinical competency evaluations [FPPE/OPPE, proctoring].
• Analyze and prepare presentations and reports regarding practitioner performance improvement and ensure quality/competence data is clear, concise and structured.
• Recognize, investigate, and validate discrepancies and adverse information obtained.
• Coordinate an appropriate evaluation of data gathered by physician leaders.
• Communicate findings and/or resulting actions to supervisor and department leadership.
• Manage the proctoring and training pathway process for physicians and Allied Health Practitioners.
• Conduct research regarding credentialing criteria for the development of new procedures and collaborate with leadership in the development of new clinical programs.
• Develop pathways and processes for education and training for new technology.
• Help identify and implement process improvement initiatives and always looking for ways to streamline processes to increase efficiency.
• Comply with accreditation and regulatory standards [TJC, ODH, CMS].
• Lead the credentialing file review session during all regulatory and CMS directed surveys.
• Be a content expert regarding credentialing and requires in depth knowledge regarding TJC, ODH, and CMS credentialing requirements, as well as the specific medical staff privileging information for the hospitals they support.
• Obtain and evaluate practitioner sanctions, complaints and adverse data to ensure compliance.
• Participate in an ongoing assessment of governing documents (bylaws/rules and regulations/policies and procedures) to ensure continuous compliance.
• Participate in surveys and audits of regulatory and accreditation agencies or organizations.
• Demonstrate an understanding of state and regulatory standards.
• Collaborate with Physician and Allied Health Practitioner leadership to develop and maintain delineation of privileges (DOPs), complex departmental and section rules and regulations.
• Lead the on-boarding process for all Physicians and Allied Health Practitioners new to an OhioHealth hospital.
• Coordinate activities to introduce new providers to the Medical Staff, Hospital leadership, and hospital associates.
• Plan and facilitate events for the Medical Staff and Allied Health Practitioners.
• Manage the billing and collection of medical staff dues.
• Create and manage both open and one-time purchase orders.
• Manage Medical Staff meetings as directed which require agenda planning, coordination with the meeting chair, tracking of follow-up items from previous meetings, coordination of guest speakers, and compiling of meeting minutes that may be reviewed by the Governing Body, and external regulatory agencies that are reviewed by the board and frequently reviewed during accreditation surveys.
• Maintain the credentialing database continuously and consistently to ensure that accurate and current information is available to all stakeholders.
• Manage the on-call directory to ensure that call schedules are maintained and accurate.
• Collaborate with providers to ensure their contact preferences are accurate so they can be contacted accurately and efficiently to prevent delays in care for patients.
• Maintain confidentiality regarding provider information.
• Audit, assess, and effectively utilize and maintain practitioner credentialing processes and information systems (e.g. files, reports, minutes, databases) as outlined by the department.
• Identify associations between seemingly independent problems or events to recognize trends, problems, and possible cause-effect relationships.
• Securely manage information as the single source of truth by effectively navigating database software and maintaining data integrity.
• Manage or participate in special projects as needed.

Benefits

• Equal Employment Opportunity
• Caring environment
• Learning as a life-long process
• Striving for excellence in the healthcare industry

What This Job Offers

• Job Type: Full-time
• Industry: Ambulatory Health Care Services
• Education Level: Bachelor's degree