Director Of Credentialing

SUMMARY

Potential to be a Senior Director level with the appropriate amount of experience.

The Director of Credentialing is responsible for administering credentialing and provider enrollment services throughout our practice network including, Delegated Credentialing, Facility Payor Enrollment, Provider Payor enrollment, and Provider's facility appointments and re-appointments. In this role, this role provides leadership to a team of credentialing and provider enrollment specialists and leads, manages, and monitors processes and procedures that support credentialing, re-credentialing, and data management to ensure compliance with all relevant standards, state and federal regulations, and health plan compliance.

ESSENTIAL FUNCTIONS

• Overseas the end-to-end credentialing process for all healthcare providers, including physicians, optometrists, mid-levels and facility payor enrollment at Eyecare Partners.

• Leads the credentialing team, cultivating a work environment that encourages teamwork, professional growth, and adherence to annual performance goals and metrics while focusing on delivering value to the company.

• Develops, Implements, and continuously improves credentialing, recredentialing, and privileging processes, policies, and procedures to ensure compliance with regulatory requirements.

• Audits and assesses the effectiveness and efficiency of both delegated and non-delegated credentialing end-to-end processes.

• Collaborates on and coordinates and supports credentialing committee activities, including scheduling, preparation, facilitation, and documentation of the meetings.

• Ensures compliance with and stays abreast of changes to legal and regulatory standards with the National Practitioner Data Bank.

• Collaborates with relevant stakeholders on mutual topics of interest; provides updates on changes regarding enrollment and credentialing. Specifically, Facilitates and participates in Payor meetings, and collaborates with RCM on credentialing and enrollment related claims projects and denials.

• Leverages technology platforms and software systems to streamline the credentialing processes, maintain records, and enhance efficiency.

• Travel up to 25% of the time required.

EDUCATION / EXPERIENCE / QUALIFICATIONS

• Bachelor's Degree required preferably in a related area of study.

• 8+ years progressive experience in provider payor enrollment, credentialing, and privileging processes.

• 4+ years of leading and developing high performing teams.

• Detailed understanding of Medicare, Medicaid, and Managed Care Plan regulations.

• Experience with credentialing platforms, related software, and websites (NPPES, CAQH, etc.)

• Detailed understanding of Medicare, Medicaid, and Managed Care Plan regulations.

• Goal Driven with a firm understanding of credentialing department KPIs.

• Must be able to work under pressure and meet deadlines, while maintaining a positive attitude and providing exemplary customer service.

• Ability to multi-task and align priorities accordingly.

SYSTEMS AND TECHNOLOGY

• Proficient in Microsoft Excel, Word, PowerPoint, Outlook