Credentialing Manager

Credentialing Miramar, Florida


Description

Position at Clear Spring Health

Group1001 is a consumer-centric, technology-driven family of insurance companies on a mission to deliver outstanding value and operational performance by combining financial strength and stability with deep insurance expertise and a can-do culture. Group1001’s culture emphasizes the importance of collaboration, communication, core business focus, risk management, and striving for outcomes. This goal extends to how we hire and onboard our most valuable assets – our employees.

Company Overview:

Clear Spring Health is part of Group One Thousand One (“Group1001”), a customer-centric insurance group whose mission is to make insurance more useful, intuitive and accessible so that everyone feels empowered to achieve financial security.  Clear Spring Health is dedicated to helping seniors protect their health and well-being by providing Medicare Advantage plans in select counties of Colorado, Illinois, North Carolina, and Virginia, plus Georgia and South Carolina.  In addition, Clear Spring Health sponsors Medicare Prescription Drug plans in 42 states.

Group 1001, and its affiliated companies, is strongly committed to providing a supportive work environment where employee differences are valued. Diversity is an essential ingredient in making Group 1001 a welcoming place to work and is fundamental in building a high-performance team. Diversity embodies all the differences that make us unique individuals.  All employees share the responsibility for maintaining a workplace culture of dignity, respect, understanding and appreciation of individual and group differences.

Job Summary:

This role is responsible for leading the Credentialing Department, reporting to VP of Provider Operations.

Main Accountabilities:

  • Manages the recruitment, training, scheduling, assignments and ongoing performance of Credentialing Coordinators, Data Management and other department staff.
  • Serves as the system-wide expert on all applicable credentialing standards (Joint Commission, NCQA, AAAHC) and State and Federal regulations.
  • Maintains current knowledge of regulations and standards, and establishes department policies and procedures compliant with all requirements
  • Provides credentialing related education and training to staff and others as needed.
  • Assists in successful accreditation/regulatory surveys and delegated credentialing audits, including presentation of requested evidence of compliance and corrective action plans.
  • Represents the department at entity credentials committee and other requested leadership meetings.
  • Ensure departmental compliance with HIPAA.
  • Serves as liaison to entity Medical Staff Offices, Medical Executive Committees, Chiefs of Staff, health plan, medical groups, Chief Medical Officers and other physician leadership.
  • Provides support and service recovery to physicians, providers and other stakeholders.

Credentialing & Verification Functions:

  • Directs the timely and accurate completion of health care professionals credentialing and re-credentialing applications.
  • Directs primary source verification and collection of documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on Joint Commission and NCQA standards, health plan requirements and credentialing policies.
  • Ensures the accurate collection and documentation of all required renewal certifications (expirables) within the required time frame.
  • Cross trains within department to support credentialing operations and provide back-up support for key functions as needed.
  • Cross trains within department to support credentialing operations and provide back-up support for key functions as needed.
  • Ensures appropriate notification to hospitals, health plans and medical groups of provider demographic changes as well as required documentation in the credentialing database.
  • Directs the processing of provider network terminations.
  • Collects/receives/audits disciplinary, OIG, and other reports as required (i.e. State Licensing Board, NPDB and other sanctioning bodies); takes appropriate action.
  • Provides consistent and timely follow-up on all outstanding credentialing/re-credentialing files, escalating issues to appropriate leadership when necessary.

Data Management & Performance Improvement:

  • Establishes reliable file collection, scanning, data capture and data entry procedures into the credentialing database.
  • Monitors the timeliness, completeness and accuracy of data collection and entry processes.
  • Prepares and presents reports on key performance measures to accountable leadership and committees.
  • Prepares credential committee reports/Meetings minutes, adverse action documentation and other required reports as requested.
  • Prepares credential committee reports/Meetings minutes, adverse action documentation and other required reports as requested.
  • Applies performance improvement and lean principles to continually evaluate and improve department performance.

Qualifications:

  • At least 2-3 years of experience in a health care and/or managed care environment, claims experience preferred.
  • Certification by the National Association of Medical Staff Services (NAMSS) as a Certified Professional Medical Staff Manager (CPMSM) or Certified Professional Credentialing Specialist (CPCS) preferred.
  • Excellent written and verbal communications skills.
  • Informational knowledge of health plan software systems, examples, QNXT, Cactus.
  • Ability to effectively manage multiple priorities.
  • Excellent written and verbal communication skills.
  • Ability to prepare and present formal presentations.
  • Strong effective interpersonal skills.
  • Ability to analyze data and track and trend variance from goals.
  • Functional computer skills in Microsoft office.