Mgr, Credentialing

PDS Health•Irving, TX

3d•$84,000 - $106,000

About The Position

The Manager of Credentialing is responsible for the leadership of the contracting, credentialing, delegated credentialing, and recredentialing functions for all PDS Health business units including dental, medical and specialty clinicians. The Manager is responsible for securing the quality, productivity, efficiency and service level of these functions while also making sure that the ongoing execution of all team members and processes are in accordance with applicable policies and procedures. The Manager will collaborate with other PDS Health department leaders, along with on and offshore vendor partners, to achieve the quickest and most efficient in-network status of supported clinicians with medical and dental insurance payors. The role is accountable to make timely, knowledge-based decisions on strategy, processes, and operational practices. The Manager must also maintain comprehensive knowledge of legal or regulatory policies across all states and payors to ensure compliance is upheld.

Requirements

5+ years of credentialing experience in a healthcare or insurance environment in lieu of a Bachelor’s degree.
2–3 years of management/supervisory experience in a credentialing or provider enrollment setting
Strong knowledge of payer processes for enrollment, re-credentialing, and revalidation.
Experience in assessing workflow, leading a team, mentoring, coaching, and training subordinates.

Nice To Haves

Experience in a mid-to-large multi-site medical or dental support organization (MSO / DSO).
Experience with Medicare, Medicaid, and commercial payer enrollment is often required
Understanding of licensure, malpractice insurance, NPI, DEA, and provider credential documents.
Certified Provider Credentialing Specialist (CPCS)
Other healthcare compliance or administration certifications
Experience with Credentialing software applications and/or general provider/payor enrollment procedures.
Knowledge/Skills/Abilities
Excellent abilities in managing the scaled daily operations of a department(s) or work unit while also a proven track record in developing short to medium term (1-3 years) goals.
Excellent organizational and time management skills.
Experience with practice management systems or EHRs (like Epic, Athena, or Dentrix if dental).
Foster employee development by providing a supportive learning environment.
Highly developed teambuilding, influencing, and collaboration skills.
Ability to direct the work of others and work as a team leader in attainment of goals.
Ability to interpret and apply policies and procedures. Ability to handle and maintain extreme confidentially with employee records, compensation information, etc.
Ability to draw valid conclusions; apply sound judgment in making decisions and make decisions under pressure.
Ability to read, analyze, and interpret documents such as professional journals, technical procedure manuals, safety rules, operating and maintenance instructions, and governmental regulations.
Proficient communication skills with a commitment to achieving predetermined goals. Ability to interpret a variety of instructions furnished in written, verbal or diagram form.

Responsibilities

Lead the Credentialing Team day-to-day operations and activities.
Mentor, develop and train team members to facilitate career growth.
Track and trend performance of team members.
Educate credentialing and other appropriate team members (clinical and operational) on payor and plan credentialing nuances.
Plan and strategize mid to longer term credentialing team needs to support PDS Health’s growth.
In partnership with the Director, Business Process Outsource (BPO), determine the most effective allocation of work effort between the core PDS Health credentialing team and our BPO partners.
In concert with other PDS Health leaders, optimize the credentialing process, including partnering with delegated credentialing committee and insurance payers to maximize delegating credentialing.
Analyze overall and individual insurance payor trends to make recommendations on workflow improvements. Ensure all capabilities of PDS Health’s credentialing software (Credential Stream) and other software technologies and automation tools (i.e. UI Path) are fully exploited.
Set agreed upon Key Performance Indicator (KPI) and Service Level (SLA) metrics. Ensure these are achieved by partnering with Director, BPO and being regularly reported.
Oversee credentialing software/database systems (e.g., CAQH, PECOS, internal platforms)
Develop and improve standard operating procedures (SOPs)
Facilitate credentialing team’s coordination and communication related to the onboarding of new clinicians with other departments, including Legal, Recruiting, People Services, IT, Learning Development, and operational field leaders.
Oversee and provide subject matter expertise on the development and maintenance of training programs, manuals, and all field / clinician facing collateral.
Ensure PDS follows all regulatory compliance rules by maintaining all doctor’s credentials and licenses.
Ensure alignment with and maintenance of audit procedures and delegated payor audits, including process adherence, document tracking, records, reports, policies and procedures for accuracy and effectiveness.
Stay updated on trends that may impact payors, plans, and the credentialing process (i.e. credentialing alternatives, business or technology partners, competitors, new plan designs, etc.).
Other duties as assigned.