Director of Medical Staff Services

District Medical Group•Phoenix, AZ

About The Position

District Medical Group (DMG) is a nonprofit, integrated multi-specialty medical group in Phoenix, Arizona with a reputation for outstanding leadership, innovation, and dedication to the patients and communities we serve. DMG employs over 750 members, including Physicians, Advance Practice Providers, independent contractors, executives, and administrative staff to provide services across all major medical specialties and subspecialties. We are proud of the commitment to patient care, education, research, and community health services the organization has supported for over 30 years. By upholding a supportive work environment through employee appreciation, collaboration, mentoring, and growth opportunity, DMG has retained countless long-tenured staff and welcomes new knowledge and initiatives. The organization offers a benefits package that includes competitive compensation and attractive health and company benefits, highlighted below. The Director of Medical Staff Services independently oversees medical staff services to develop, manage and monitor processes and procedures to support credentialing, recredentialing, privileging, expirations, health plan credentialing, contracting and delegation, as well as provider onboarding and other services to ensure compliance with the appropriate accrediting and regulatory agencies.

Requirements

Knowledge of the health plan enrollment / credentialing process and the requirements of each health plan.
Knowledge of the contracting process as it relates to credentialing providers.
Knowledge of physician revenue cycle and the connection with health plan enrollment and delegated responsibilities.
Understand managed care concepts, key functions, processes, terminology, and work products.
Ability to provide team development through staff education and training.
Exhibit a high degree of responsibility for confidential matters regarding legal matters, privacy issues, information technology, and data integrity.
Strong interpersonal and communication skills, both verbally and in writing, and the ability to work effectively with a wide range of constituencies in a diverse community.
Establish productive, cooperative relationships with subordinates, peers, management, and stakeholders both internal and external to the organization.
Database management skills ability to process computer data and to format and generate reports.
Working knowledge of database software platforms specifically Microsoft Office package, MD Staff credentialing database or another comparable program.
Knowledge of medical staff policies, regulations, and bylaws and the legal environment within which they operate.
Thorough knowledge of the current credentialing and delegation standards and guidelines of the National Council for Quality Assurance (NCQA); working knowledge of hospital accrediting bodies (i.e., DNV, Joint Commission) medical staff standards for credentialing and privileging.
Knowledge of medical terminology and claims process procedure, CPT-ICD coding, Medicare, Medicaid, claims payment rules and guidelines.
Understanding/compliance of HIPAA laws and regulations.
Understand concepts, key functions, terminology, and work products under legal, risk, human resources, and budgeting.
Analytical problem solving and decision making.
Must be available to work extended hours.
Exhibit confidence and professional diplomacy while identifying, organizing, facilitating and/or sustaining mutually beneficial partnerships and alliances with people at all levels internally and externally.
Demonstrate an understanding of the interrelationships, roles, decision-makers, and responsibilities of the organization.
Value and model integrity and honesty by acting in a just, fair, and ethical manner and encouraging ethical behavior among others.
Inspire trust and confidence among stakeholders through reliability, authenticity, and accountability.
High school diploma or equivalent
Bachelor’s degree or equivalent combination of training, education, and experience in related field
10+ years’ experience in medical services profession, extensive experience in credentialing, provider enrollment and health plan delegation
7+ years’ experience in a leadership role in medical environment
5+ years’ experience with NCQA credentialing standards
3+ years’ experience of hospital accreditation requirements

Nice To Haves

Certification by the National Association of Medical Staff Services in Certified Professional Medical Services Management (CPMSM) or Certified Professional Credentialing Specialist (CPCS) preferred

Responsibilities

Provide administrative oversight to ensure compliance with accrediting and regulatory agencies (i.e., NCQA, Joint Commission, DNV, URAC, and Federal and State Agencies) as it relates to credentialing and health plan regulations while developing and maintaining a working knowledge of the statutes and laws.
Assure adequate and efficient staffing levels and schedules to meet productivity and quality measures.
Manage the training and education of staff with respect to policies, procedures, regulatory agency requirements, health plan policies and procedures.
Maintain job descriptions and performance standards for department staff.
Establish department goals and objectives including project prioritization and deadlines.
Responsible and accountable for the maintenance of provider credentialing processes and information systems (e.g., files, reports, minutes, databases).
Oversee the verification and documentation of expirable documents using acceptable verification sources to ensure compliance with accreditation and regulatory standards.
Meet with key organization stakeholders to develop and maintain on-boarding processes (orientation, training activities) to assist initial applicants and to meet education requirements.
Develop and maintain professional networking contacts at hospitals and health plans promoting DMG and representing DMG at third party contractor audit of credentials files.
Develop efficient processes, and the continuous improvement of, the submission of data and applications to the contracted and government payors in a manner commensurate with their expectations, policies, and accreditation standards; ensure discrepancies are addressed promptly and the proper follow-ups are completed in a timely manner; review escalated issues and use findings to improve departmental operations; promote continuous learning and adaption of plan standards and regulations.
Apply regulatory standards to the credentialing process, in order to obtain delegated credentialing status with all willing health plans. If required, develop action plans in accordance with recommendations received from health plans during delegated audits to ensure continued delegation.
Maintain excellent working knowledge of National Committee on Quality Assurance (NCQA), hospital accrediting bodies (i.e., DNV, Joint Commission), State and Federal regulations related to credentialing and health plan compliance.
Aid Central Billing Office, Prior Authorization, Division staff and health plan representatives with issues that may be hindering the billing process related to a provider’s health plan status to assist in the reimbursement process.
Develop and maintain, revising as required, DMG’s Credentialing and Quality Assurance Plan to standardize and facilitate all aspects of provider credentialing processes, assuring that all regulatory agency requirements addressed.
Oversee management of credentialing database, ensure that accurate and current information is available to all stakeholders by manipulating provider database to extract information for ad hoc reports, surveys, and internal and external extracts. Design and implement statistical reports to extract data in format required by various regulatory agencies. Investigate and resolve database inconsistencies and institute policy to ensure process improvement.

Benefits

Medical, Dental, Vision, and many additional ancillary benefits EFFECTIVE DAY ONE
401(k) contribution options, with employer match up to 6%
Access to Retirement Advisors
Employer-paid Disability
A Health Savings Account option with employer contribution
Flexible Spending Account options, including Dependent Care FSA
Rich Wellness Program and EAP, at no cost to the employee
Fitness location memberships
Pet care discount program
Generous PTO allocation, increasing after 3 years
10 paid Holidays
Up to 40 hours Paid Sick Time annually