Credentialing Manager

Operations San Diego, California


Description

American Specialty Health, Inc. is seeking a Manager, Practitioner Contract Administration to oversee our Practitioner Contract Administration Department. This position will oversee Practitioner Contract Administration Staff and for the department to meet all performance standards. Also, maintains compliance to NCQA and URAC standards and business objectives as it relates to Practitioner Contract Administration and Services departments.  

You are invited to learn more about American Specialty Health’s events on our events page.  

Responsibilities

·        Responsible to help maintain corporate objectives through the credentialing and maintenance of the company network of practitioners.

·        Manages the practitioner credentialing function for company network of practitioners, with duties including ongoing compliance, and monthly monitoring of performance.

·        Ensuring the appropriate processes are in place to monitor and maintain systematic, timely credentialing and re-credentialing of network practitioners and providers.

·        Develop and implementing standards to ensure the accuracy of practitioner credentialing.

·        Coordinating the analysis of data relevant to the credentialing process.

·        Ensure the appropriate information is prepared for administrative review and credentialing committee relevant to credentialing criteria /data.

·        Manage projects related to the credentialing program within the department and by collaborating with other departments. 

·        Assist in preparation for state and federal audits, responding to client auditor’s inquiries and preparing responses to auditor findings.

·        Supervises and trains the practitioner credentialing examiners, primary verification examiners, and front end examiners, supervisors and team leads.

·        Training staff with the credentialing function and acting as a resource for staff including training staff on NCQA and URAC guidelines.

·        Monitoring and evaluating day to day activities for the credentialing staff.

·        Responding to non-routine and difficult credentialing issues when the staff requires assistance.

·        Conduct regular meetings with staff and provide back-up support for the credentialing function when the staff are out of the office or unavailable.

·        Collaborates with all levels of management across functional departments to achieve departmental goals and objectives.

·        Interfaces effectively with various members of management and staff to improve various processes by way of discussion, analysis, internal audit, recommendation and implementation in order to assure quality.

·        Creates and revises credentialing policies, procedures, and workflows to ensure compliance with all regulatory accreditation, health plan delegation and contractual credentialing requirements.

·        Ensure the policies and procedures related to credentialing are current and reflect company and industry standards.

·        Research various issues related to credentialing policies and procedures and making recommendations to leadership and credentialing committee for consideration.

·        Work closely with leadership of the delegated credentialing process for appropriate sub-contractors.

·        Accountable for achieving internal and external performance standards: reports credentialing results to leadership, identifying and resolving barriers to achieving results.

·        Accountable for hiring, training, and retaining high performance, injury free team members.

·        Conveys clear and concise messages appropriate to intended audience; represents the company in a professional manner through effective oral and written communication.

·        Demonstrates good judgment through appropriate delegation while maintaining proper oversight and follow up; prepares leadership staff for situational delegation.

·        Monitor the quantity and quality of the staff to ensure compliance with productivity and quality measures. Identifies barriers to meeting goals and implements activities to alleviate barriers.

·        Uses resources effectively (people, time, expenses) to manage within or below budgetary targets based upon current business environment.

·        Completes performance reviews in a timely manner.

·        Assists staff in working through barriers to obtaining objectives.

·        Serves as an example for motivational behavior and teamwork.

·        Foresees needs for improvement of processes and recommends plans of action to leadership.

Qualifications

·        Bachelor’s Degree in Business, Health Administration, Public Administration or equivalent experience.  If equivalent experience, high school diploma required.                             

·        5 years of progressive experience, 2 of which have been in a supervisory capacity

·        or management level experience in managed care, medical staff services, health services or government assistance programs; or an equivalent combination of education and experience which would provide the required knowledge, skills and abilities.

·        Certified Provider Credentialing Specialist (CPCS) preferred.

·        Familiarity with specialty health plans (HMO, PPO, POS and related plans).

·        Proficient with Microsoft Office, including Access, Word, Excel and Power Point.

·        Ability to plan, assign, supervise and evaluate the work of others, and to monitor goals, objectives, deadlines and priorities.

·        Ability to manage multiple projects effectively while facilitating group success.

·        Ability to analyze, interpret and synthesize a wide range of information, including legal and contract language, policies, standards and guidelines.

·        Ability to analyze complex data related to credentialing.

·        Knowledge of Credentialing/re-credentialing, delegation oversight, NCQA, URAC and managed care experience (Medicaid, Medicare, and Commercial) required.

·        Knowledge of the performance improvement process.

·        The ability to think strategically, implement tactically and the ability to position the organization for the future.

·        Preferred knowledge of CAQH.

Core Competencies

·        Demonstrated ability to interact in a positive, respectful manner and establish and maintain cooperative working relationships.

·        Ability to display excellent customer service to meet the needs and expectations of both internal and external customers.

·        Excellent listening and interpersonal communication skills to identify critical core competencies based on success factors and organizational environment.

·        Ability to effectively organize, prioritize, multi-task and manage time.

·        Demonstrated accuracy and productivity in a changing environment with constant interruptions.

·        Demonstrated ability to analyze information, problems, issues, situations and procedures to develop effective solutions.

·        Ability to exercise strict confidentiality in all matters.

Mobility

Primarily sedentary, able to sit for long periods of time. 

Physical Requirements

Ability to speak, see and hear other personnel and/or objects.  Ability to communicate both in verbal and written form. Ability to travel within the facility. Capable of using a telephone and computer keyboard.  Ability to lift up to 10 lbs.

Environmental Conditions

Usual office setting.  

American Specialty Health is an Equal Opportunity/Affirmative Action Employer.  

All qualified applicants will receive consideration for employment without regard to race, color, religion, sex including sexual orientation and gender identity, national origin, disability, protected Veteran Status, or any other characteristic protected by applicable federal, state, or local law.   

Please view Equal Employment Opportunity Posters provided by OFCCP here.  

If you are a qualified individual with a disability or a disabled veteran, you have the right to request an accommodation if you are unable or limited in your ability to use or access our career center as a result of your disability. To request an accommodation, contact our Human Resources Department at (800) 848-3555 x6702.  

ASH will not discharge or in any other manner discriminate against employees or applicants because they have inquired about, discussed, or disclosed their own pay or the pay of another employee or applicant. However, employees who have access to the compensation information of other employees or applicants as a part of their essential job functions cannot disclose the pay of other employees or applicants to individuals who do not otherwise have access to compensation information, unless the disclosure is (a) in response to a formal complaint or charge, (b) in furtherance of an investigation, proceeding, hearing, or action, including an investigation conducted by the employer, or (c) consistent with the Company’s legal duty to furnish information.