Director of Credentialing and Payer Enrollment (4087)

WACO FAMILY MEDICINE•Waco, TX

2d•Onsite

About The Position

The Director of Credentialing and Payer Enrollment is responsible for managing the internal credentialing and privileging (C&P) process to ensure all clinical staff are fully credentialed and privileged. This role also manages the payer enrollment process, including establishing and renegotiating payer contracts, managing site and clinician enrollment with various payers, and overseeing CAQH profiles. The Director will supervise C&P and payer enrollment staff, ensure optimal use of technology like VerityStream, and collaborate with other departments to resolve issues and minimize lost revenue. A commitment to the mission and values of Waco Family Medicine is essential, along with the ability to provide exceptional patient care.

Requirements

Associate or bachelor’s degree; advanced degree (e.g., MBA, MHA) preferred.
Minimum of 2 years of experience in a related role.
Management experience strongly preferred.
Strong understanding of healthcare requirements related to credentialing and privileging of clinical staff.
Ability to navigate complex administrative requirements for enrolling clinical sites and staff with Medicare, Medicaid, and commercial insurance plans.
Strong ability to manage multiple tasks, prioritize work efficiently and proactively follow up on unresolved issues.
Excellent verbal and written communication skills to interact effectively with staff and payers.
Attention to detail and strong analytical skills, including ability to navigate complex bureaucratic systems.
Familiarity with or ability to quickly master credentialing software (VerityStream), electronic health record systems (Epic), and Microsoft Office suite.
Commitment to providing excellent service to both internal and external stakeholders.
Ability to analyze data, trends, and patterns.
Skill in exercising initiative, judgment, discretion, and decision-making to achieve organizational objectives.
Ability to understand and adhere to complex compliance requirements.
Visual and auditory accuracy.
Indoor setting.
Continuous use of computer and other technology.
Long periods of sitting and walking.
Frequent use of telephone.
Continuous repetitive grasping and manipulation of both hands.
Continuous conversational communication.
Occasional reaching, standing, squatting, bending, kneeling, twisting and climbing.
Occasionally carrying, lifting, pushing, and pulling up to 25 lbs.
Infrequent use of personal transportation (possess a valid Texas driver’s license and appropriate liability insurance).
Occasionally working in confined, noisy, dusty areas.
Understand/carry out simple/detailed, oral/written instructions.
Memorize and retain instructions.
Read and interpret detailed specifications.

Nice To Haves

Advanced degree (e.g., MBA, MHA) preferred.

Responsibilities

Manage internal credentialing and privileging (C&P) process, including ensuring all clinical staff are fully credentialed and privileged upon hire and that credentials and privileges are reviewed and renewed at least every 2 years.
Ensure that clinical staff maintain valid, active licenses and registrations.
Ensure C&P policy and procedures fulfill all HRSA and other applicable requirements.
Ensure C&P process is streamlined and as efficient as possible for clinical staff and C&P committee.
Supervise C&P staff and ensure that C&P committee operates effectively.
Ensure optimal use of available technology (VerityStream) to support streamlined C&P process.
Ensure that all required C&P documents are properly collected, reviewed and archived.
Prepare for and participate in C&P audits and other reviews (e.g., HRSA OSV and FTCA site visits).
Manage payer enrollment process, including establishing and renegotiating payer contracts, ensuring optimal payment rates, clinic site enrollment and revalidation with CMS, Medicaid and commercial insurance, and clinician enrollment and revalidation with CMS, Medicaid and commercial insurance.
Manage clinician CAQH profiles and other administrative requirements of payer enrollment.
Creation and management of clinician and clinical site NPI numbers.
Ongoing follow-up on payer enrollment delays and errors (e.g., inappropriate disenrollment).
Navigate CMS, TMHP and insurance company bureaucracies to effectively address payer enrollment issues and reduce lost revenue due to enrollment errors and delays.
Create and implement payer enrollment procedures to ensure that all aspects of payer enrollment are performed promptly and accurately and that overall enrollment timeline is minimized.
Supervise payer enrollment staff.
Initially collaborate with third-party payer enrollment service while developing plan to promptly insource all payer enrollment activities.
Collaborate with Director of Billing Operations to track and resolve denials related to payer enrollment.
Provide payer enrollment status information to relevant stakeholders (practice managers, schedulers, etc.) to ensure patients are scheduled with in-network clinicians.
Demonstrate a commitment to the mission, core values, and goals of Waco Family Medicine and its healthcare delivery, including the ability to deliver exceptional patient focus with quality, compassion, and respect.
Other duties as assigned by supervisor.