Director, Provider Data Management

Altais

About The Position

Are you looking to join a fast-growing, dynamic team? We’re a collaborative, purpose-driven group that’s passionate about transforming healthcare from the inside out. At Altais, we support one another, adapt quickly, and work with integrity as we build a better experience for physicians and their patients. The Director, Provider Data Management is responsible for the end to end process driving accurate, compliant and timely provider data management. This role will be responsible to develop processes and procedures driving application management, intake, credentialing, re-credentialing, compliance monitoring, expirable data management, and delegated credentialing contract process to ensure compliance with National Committee for Quality Assurance (NCQA), CAQH standards, CMS, state and federal regulations and individual health plan requirements, roster and directory management, provider demographic management, and provider termination processes. The Director, Provider Data Management will be responsible for credentialing analysis, quality assurance, planning and forecasting, client/vendor relationships and continuous improvement of operational performance. This role leads and mentors a team responsible for services throughout affiliated entities including employed clinicians, vendors providing clinical services on the MSOs behalf, as well as MSO services for any other medical group or IPA. They will work cooperatively with staff, physicians, leadership, department directors and vendors. The Director, Provider Data Management establishes the operations of the provider data intake and credentialing functions by developing Credentialing related organizational policies and procedures. The Director, Provider Data Management will ensure compliance with company policies, regulatory compliance, manage employees, meet expectations of customers, and achieve operational goals and objectives. This role will lead delegated functions for all our Health Plan Partners for all lines of business as well as all oversight and audit components are critical functions of this position including developing and execution of remediation plans. Additionally, this role will oversee the interdependencies between departments, consistently maintaining knowledge and understanding of the impact to providers and how that may affect overall business operations and financial outcomes. The leader will champion increased provider satisfaction by working with Network Operations, Contracting and Network Development to expedite the contracting process and deliver best in class service. This role will collaborate across IT to ensure roster and directory delivery is accurate and timely. The Director will leverage technology to drive automation and efficiencies across the department. The Director will be involved in high-level decision-making processes such as setting long-term goals, leading initiatives and will have the ability to manage plans as new customers or IPAs are contracted while understanding the impact to staffing, monthly trends and onboarding.

Requirements

Bachelor’s degree or equivalent to 4-year university degree, preferably in healthcare related field of study.
Minimum of 10 years of credentialing, or regulatory affairs experience, preferably in a managed care or insurance environment.
Ability to work with physicians in a collaborative manner.
6 years of leadership experience.
Experience working with Management Services Organization (MSO), Health Plan or large at-risk provider practice; and IPA or medical groups.
Credentialing software experience.
Experience leading Health Plan audit activities.
Experience presenting to leadership – outlining plans for future success.
Ability to develop management reports.
Experience with and knowledge of CAQH and credentialing processes.
Knowledge of delegated credentialing and verification.
Knowledge of related accreditation and certification requirements.
Knowledge of medical credentialing procedures and standards.
Understands the use of credentialing software and automation to improve workflow
Understands how to support growth and scale as the organization grows customers
Ability to work with internal stakeholders to develop technical solutions to improve accuracy and efficiency of processes and reporting
Excellent communication skills, both written and verbal, as well as strong organizational and administrative abilities
Advanced Excel knowledge
Ability to create, implement, document and audit policies and procedures.
Ability to effectively prioritize and execute tasks in a high-pressure environment.
Ability to lead and manage others in a remote environment ensuring internal controls are followed.
Strong interpersonal, project management, and mentoring skills.
Must be eligible to take National Association Medical Staff Services (NAMSS), Certified Provider Credentialing Specialist exam within 18 months of employment

Responsibilities

Provide leadership / coaching to the credentialing team staff, ensuring function initiatives and deliverables are complete and accurate in a timely manner
Responsible for the oversight of processing credentialing applications accurately and promptly in accordance with Credentialing policies and procedures and in full compliance with all regulations with a continued focus on delivery of a high-quality product with the greatest level of efficiency
Owns end to end delegated credentialing process, including management of the Provider Directory and any related Provider Engagement Portal, or equivalent
Direct audit preparation of materials and files necessary to comply with external audits by payors and/or governmental agencies
Manages relationships with health plan delegation oversight committee members.
Leads process for initial and re-credentialing review by the Credentialing Committee and the Clinical Advisory Group for exception physicians
Conduct on-going program evaluations and audits of data integrity
Identifies opportunities and root-cause to improve the provider data management, credentialing and roster/directories production process and use of technology; identifies and resolves technical, operational and organization problems outside own team
Oversee provider health plan enrollment for employed physicians
Conduct audits of the credentialing database, confirming accurate input of provider data, and verifying accuracy of modifications made to the database and downstream impacts to other reporting tools and functions
Responsible for provider data integration of newly acquired entities or new customers including software and staff, ensures smooth transition of providers when on-boarding, for new contracts and during acquisitions, in collaboration with Network Operations
Develop monthly management reports illustrating status, back-log, and trends to be used at Monthly Operating Review
Manages staff including interviewing and selecting qualified candidates, coaching for career development, training, monitor productivity and accuracy, conducting performance evaluations, addressing guidelines and changes, consistent application of HR policies and procedures, and guide staff to confident decision-making.
Serves as SME and provides strategic direction for business requirements for producer data management and credentialing technologies
Support, participate and contribute to the development and growth of credentialing, customer service and provider services functions
Assumes responsibility for own personal continuing education and developmental needs; attends meetings, workshops to enrich personal knowledge, growth, and management skills.
Demonstrates the ability to be flexible, organized and function under stressful situations.
Fosters good public relations for the company and the client.
Independently resolves issues and develops solutions for existing problems to be escalated to internal leadership where appropriate.