Position: Credentialing, Team Lead

Job Description

Position: Credentialing, Team Lead

Reports To:Manager, Credentialing

Department:Human Resources

Status:Non Exempt

Location:Scottsdale, AZ

POSITION SUMMARY

The Credentialing, Team Lead is responsible for credentialing and recredentialing Matrix Medical Network (Matrix) practitioners, administrative functions for Matrix Credentialing Committee meetings and ensuring enrollment with participating client health plans. Credentialing functions include, but are not limited to, processing Matrix Credentialing Applications, performing primary source verifications and updating and maintaining Matrix credentialing database in accordance with internal policies and procedures, client health plan contracts, National Committee for Quality Assurance (NCQA), URAC, The Joint Commission (TJC) and Center for Medicare Services (CMS) guidelines as well as applicable state and federal requirements.

POSITION RESPONSIBILITIES:

• Perform the initial credentialing and recredentialing functions for employed and contracted Matrix practitioners, which may include collaborating physicians and Locum Tenens.
• Review practitioner applications for completion and accuracy and ensure appropriate follow-up; monitor and report on the credentialing progress of each practitioner.
• Prepare practitioner credentialing and recredentialing files for review by the Matrix Credentialing Committee, attend meetings, draft and maintain meeting minutes reflecting committee peer review, approvals and denials.
• Monitor accuracy of client health plan provider information and provider listing and ensure updated rosters are submitted to client health plan and reconciled for accuracy with client health plan.
• Assure client health plan deadlines are met and track initial and follow-up communication / correspondence with practitioners, client health plan and others, as needed.
• Coordinate with client health plan to ensure practitioner credentialing and enrollment lag time is at minimum levels; serve as primary liaison with client health plan for any practitioner data issues.
• Create and maintain databases to assimilate and track client health plan information and practitioner credentialing and enrollment requirements; prepare standard and ad hoc reports as needed; analyze and maintain all reports related to practitioner credentialing and enrollment with client health plans.
• Take a lead role with special studies and/or projects related to provider on-boarding, credentialing and client health plan credentialing and practitioner enrollment.
• Assist Manager with development and implementation of project action plans, participate in special projects as needed to evaluate client health plan operational requirements and reimbursement.

• Research practitioner issues such as payment denials due to client health plan participation status, practitioner specialty and service locations and notifies appropriate parties.
• Maintain timely and accurate data entry and periodically revise practitioner data in the Matrix credentialing database; maintain practitioner paper and electronic data files for Matrix practitioners; use the CAQH system to submit practitioner data as required by some client health plans to credential individual practitioners.
• Provide introductory and ongoing training and education to staff to ensure that Policies and Procedures are followed.
• Meet with the Manager regularly to effectively communicate and resolve issues, set and prioritize goals and improve processes.
• Assist with staff communication, providing updates, resolving issues, setting goals, and maintaining standards.
• Handle difficult and / or escalated internal and external client follow up issues.
• Ensure timely and accurate credentialing and recredentialing application submissions for each practitioner as it relates to each client health plan; monitor and report progress of each practitioner
• Enroll practitioners with all appropriate client health plans; monitor and report on progress of each practitioner
• Ensure all practitioners who require collaboration agreements are appropriately assigned to a collaborating physician and the agreement is executed by both parties; monitor and report progress of each practitioner
• Ensure employed practitioners are enrolled under the Matrix professional liability insurance plan; monitor and report progress on each practitioner
• Respond to all practitioner, client health plan and internal inquiries in a timely manner within one (1) business day
• Monitor expiring licensure, board and professional certifications and other expirable documents with practitioners within the prescribed Matrix timeframes as outlined in the policies and procedures, assisting practitioners with timely renewal as appropriate and escalating to manager and field management as appropriate
• Conduct sanctions and compliance monitoring and alert Manager of any undisclosed negative findings immediately
• Assist traveling practitioners with obtaining new state licenses in areas identified by the clinical management team; monitor and report progress of each practitioner
• Adhere to Matrix policies and procedures including timely delivery of completed work and use of resources
• Identify, analyze and resolve extraordinary information, discrepancies, time gaps and other idiosyncrasies that could adversely impact ability to credential and enroll practitioners and ultimately bill and obtain reimbursement for services rendered; discover and convey problems to Manager so that the optimal course of action is taken by making sound decisions in accordance with department and corporate guidelines
• Utilize extensive internet and telephone communication to obtain critical pertinent information
• Keep Manager informed of potential credentialing or enrollment issues
• Other duties as assigned

POSITION REQUIREMENTS:

Educational Requirements

Associates or Bachelors in Business, Finance, Health Care or related field or high school diploma and relevant combination of education and experience

Required Skills and Abilities

• Experience with medical and professional credentialing processes, policies and procedures, including delegated credentialing requirements.
• Familiarity with practitioner billing and claims payment system requirements as related to practitioner enrollment.
• Minimum of three years hands-on credentialing experience in a health care setting to include up to two years of practitioner enrollment, credentialing or network services experience.
• Demonstrated ability to work independently.
• Proven ability to manage multiple projects efficiently and accurately.
• Demonstrated effective analytical skills needed to assess compliance, record, analyze and interpret data into meaningful formats.

• Proven effective written and verbal communication skills.

• Demonstrated ability and commitment to excellent customer service to maintain and ensure effective working relationships with internal and external clients
• Ability to adapt to change and meet deadlines.
• Demonstrated attention to detail and high degree of accuracy.
• Requires exceptional critical thinking skills, sounds judgment and the ability to communicate in an articulate and sensitive manner with practitioners, administrators, legal counsel and client credentialing personnel.
• Experience with MS Office

Preferred

• Certified Practitioner Credentialing Specialist (CPCS)
• Experience with MD-Staff or similar practitioner credentialing, data collection and record management system
• Experience with NCQA, URAC, TJC and /or CMS guidelines and standards related to credentialing
• Progressive supervisory experience highly desired

Supervisory Responsibility

No supervisory responsibilities.

Travel Requirements

No travel required.

Work Conditions

General office environment.

The preceding functions may not be comprehensive in scope regarding work performed by an employee assigned to this position classification. Management reserves the right to add, modify, change or rescind the work assignments of this position. Management also reserves the right to make reasonable accommodations so that a qualified employee(s) can perform the essential functions of the position.