Job Description

Position: Manager, Credentialing

Reports To:Director, Credentialing

Department:Human Resources

Status:Exempt

Location:Scottsdale, AZ

POSITION SUMMARY

The Credentialing Manager (Manager) participates in and supervises the daily operations and activities of the Matrix Medical Network (Matrix) Credentialing Department to ensure that practitioner credentialing applications are processed accurately, in a timely manner and in accordance with NCQA and CMS standards and guidelines.The Manager is responsible for assisting in managing relationships with client health plans, network management personnel and oversight of processes involving credentialing, practitioner enrollment and delegated credentialing agreements on behalf of Matrix.

This Manager also has accountability for delegation oversight of those entities to which the credentialing function has been sub-delegated. The positionprovides managerial support to the Credentialing Committee and is responsible for enforcing the established practitioner appeal process.The Manager collaborates with internal department staff to identify barriers to timely application processing and offers suggestions for improvement on a system wide basis. The Manager is responsible for the completion of client health plan initiatives and monitors progress with established goals and metrics. The Manager works closely and cooperatively with Talent Acquisition and provides ongoing supervision of the Credentialing Specialist(s) and Credentialing Analyst(s).

POSITION RESPONSIBILITIES:

  • Prepare management and operational reports for internal and external customers
  • Communicate and work to improve interdepartmental relationships with Credentialing, Recruitment, Human Resources, Logistics, Client Services, Billing, Business Operations and other designated units
  • Assist in the review, development and maintenance of Credentialing Policies and Procedures, desktop policies and advises on the development of critical corporate guidelines and best practices
  • Conduct delegation oversight reviews and audits of contracted sub-delegates, provides reports to the client health plans in accordance with contractual provisions; prepare reports for the Credentials Committee, Quality Improvement and Compliance Committees; responsible for timely and accurate review and implementation of corrective action plans established by client health plans and/or internal departments
  • Complete ongoing file review on an intermittent basis to identify objectives, error rates and use data as an opportunity to counsel staff, as appropriate
  • Establish and maintain production and quality metrics for Credentialing Specialist(s) and/or Credentialing Assistant(s)
  • Research and analyze complex issues, ensure appropriate documentation to identify outcomes and accurately interpret internal and external guidelines and policies
  • Develop, implement and manage processes to create, update and maintain practitioner files for enrollment purposes and for ensuring accurate and timely completion of credentialing and practitioner enrollment
  • Effect interdepartmental collaboration and coordination to maximize efficiency and effectiveness of practitioner credentialing and enrollment as well as to maintain documentation necessary for verification, accreditation and credentialing delegation of the organization
  • Facilitate problem solving of operational issues through collaboration with client health plans and internal stakeholders
  • Identify and communicate all concerns regarding practitioner credentialing and enrollment, including excessive timeframes for outstanding applications to the Recruitment/Onboarding, Human Resources, Resource Planning & Administration, Production Planning & Control, Account Management, Billing, Business Operations and other designated units
  • Make recommendations for optimizing contract language as it relates to credentialing, practitioner enrollment and delegated credentialing
  • Manage multiple projects simultaneously and under tight deadlines
  • Resolve contract and claim issues related to practitioner enrollment and identify and communicate opportunities for process improvement
  • Respond to inquiries regarding practitioner credentialing and enrollment
  • Track applications through the practitioner credentialing and enrollment process with the client health plans to ensure timely processing until credentialing is complete and practitioner enrollment effective dates are obtained prior to or as close as possible to the practitioner start date
  • Manage special studies and/or projects related to practitioner on-boarding, credentialing and client health plan practitioner enrollment and prepare report of findings and recommendations as appropriate
  • Collaborate with the Legal Department to obtain copies of client health plan contracts, review for credentialing requirement compliance, advise Director and Senior Legal Counsel of any exceptions or lack thereof and develop time sensitive corrective action plan(s) to address and remedy deficiencies
  • Effective improvement of operational processes to achieve maximum efficiency, accuracy and data integrity
  • Participate in the internal monitoring of Chapters 11 and 13 of the Medicare Managed Care Manual
  • Ensure compliance with NCQA and CMS standards and guidelines; identify and monitor The Joint Commission, URAC, AAAHC accreditation policies and other federal and state legislation, as appropriate
  • Develop agenda and supplemental materials for the Credentials Committee and prepare ad hoc reports for the Quality Improvement and Compliance Committees
  • Provide management support to the Credentialing Specialist(s) and/or Credentialing Assistant(s)
  • Maintainconfidentiality of all credentialing information in compliance with federal and state statutes, as well as Matrix policies
  • Support professional development of Credentialing Specialist(s) and/or Credentialing Assistant(s)
  • Perform miscellaneous job related duties as assigned

POSITION REQUIREMENTS:

Educational Requirements

  • Bachelor’s in Business, Finance, Health Care or related field preferred; or high school diploma and appropriate combination of education and experience

Required Skills and Abilities

  • Effective leadership skills at all levels
  • Ability to interface and collaborate with internal and external professionals, including accreditation and government regulation representatives
  • Exceptional verbal and written communication aptitude, with proven ability to positivelyinfluence behavior
  • Conflict resolution and change managementcompetence
  • Process and operational improvementexperience
  • Independent and logical processing proficiency
  • Highly self directed, motivated and able to work independently with minimum level of supervision
  • Professional, courteous demeanor and attire
  • Excellent administrative and organizational skills
  • Detail oriented while keeping broader perspectives in sight
  • Strong computer skills a necessity
  • Minimum of three years of experience with credentialing in a Medicare Managed Care Plan or large provider group with Medicare contracts;or up to three years experience in a health care setting, including two years of practitioner enrollment, credentialing or provider network management experience
  • Minimum of three years of progressive managementexperience required; five years of progressive management experience strongly preferred
  • Participation in CMS credentialing audits or experience conducting CMSrelated internal compliance audits
  • Experience in developing and implementing policies and procedures, desktop procedures and work flow diagrams
  • Experience in training, educating and coaching department staff as well as internal and external customers to achieve streamlined process and meet corporate goals
  • Excellent analytical, data aggregation and customer service skills required
  • High level of proficiency with Microsoft Office programs and the internet
  • 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
  • Demonstrated ability to work independently
  • Ability to manage multiple projects efficiently and accurately
  • Strong analytical skills needed to assess compliance, record, analyze and interpret data into meaningful formats
  • Strong written and verbal communication skills
  • Demonstrate ability and commitment to excellent customer service to develop and maintain effective working relationships with internal and external clients
  • Able to effectively manage conflicting priorities, adapt to ever changing responsibilities and meet highly structured deadlines
  • Exceptional attention to detail and accuracy
  • Excellent critical thinking skills, professionalism, reliable judgment and the ability to communicate in an articulate and sensitive manner with practitioners, administrators, legal counsel, team members and client health plans

Preferred

  • Current Certified Practitioner Credentialing Specialist (CPCS) and/or Certified Professional Medical Services Management (CPMSM) designation through the National Association of Medical Staff Services (NAMSS)
  • Experience with MD-Staff or similar practitioner credentialing, data collection and record management system
  • Experience with NCQA, URAC, The Joint Commission and/or AAAHC guidelines and standards related to credentialing and delegation
  • Proficiency with Microsoft Office programs

Supervisory Responsibility

  • Direct management and oversight responsibility for Credentialing Team, including Credentialing Specialist(s), Credentialing Assistant(s), and temporary personnel

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.

01/20/2014

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