Manager Credentialing And Provider Data Management

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The Manager, Credentialing and Provider Data Management (PDM) will oversee all aspects of Peak Health's Credentialing and Provider Data Management process and will be an integral member of the health plan's Provider Relations leadership team. Responsibilities of the Manager Credentialing and Provider Data Management will include the direct supervision of day-to-day operations of credentialing to support, develop, manage, and monitor processes and procedures for credentialing, re-credentialing, expirable data management, and delegated functions for all lines of business. Additionally, this role will be responsible for processes and procedures for provider data management related to Peak Health's Provider Directory.

The Manager Credentialing/Provider Data Management will be responsible for the administrative aspects for all credentialing functions needed to meet health plan and accrediting body requirements including but not limited to National Committee for Quality Assurance (NCQA) and CMS. This role, in combination with the Credentialing team is to maintain procedures and processes in line with all regulation and compliance requirements.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1.Bachelor's Degree in Business Administration, Healthcare Administration, or other related field/experience

EXPERIENCE:

1.Five (5) years' experience working in credentialing, preferably in managed care setting

2.One (1) year of supervisor experience.

3.Completion of NAMSS Certified Provider Credentialing Specialist exam within 18 months of hire

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1.Master's Degree in Healthcare Administration, Business Administration or other advanced level of education.

EXPERIENCE:

1.Severn (7) years professional experience working in credentialing, with 2+ years of employee/team management experience

2.Experience utilizing HealthStream's (VerityStream) CredentialStream credentialing software application platform

3.NAMSS Credentialing Certification within 18 months of employment.

4.Experience utilizing credentialing software applications

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.

They are not intended to be constructed as an all-inclusive list of all responsibilities and duties. Other duties may be assigned.

1.Plan, organize, direct, and effectively manage the responsibility for overseeing the day-to-day operations, hiring, team building activities, training, supervision of department staff, corrective action process, mentoring, coaching employees, and completing performance reviews

2.Accountable for establishing, contributing, and implementation of standards applicable to provider staff relating to credentialing and administrative functions in compliance with credentialing, regulatory and accreditation requirements.

3.Prepare key credentialing operational reports for internal and external partners that drive business decisions and impact strategic planning. Develop monthly management reports illustrating status, back-log, and trends.

4.Maintain comprehensive knowledge of both state and federal statutory requirements to ensure that all legal, licensure and accreditation standards, due dates and deadlines are met.

5.Assure credentialing activities are integrated and administered by the department in partnership with partner Committees, including Credentials and Quality Improvement Committees (QIC).

6.Work with Senior leadership to support certification and accreditation processes with National Committee for Quality Assurance (NCQA)

7.Serve as an expert in the administration and maintenance of credentialing and provider data management systems, including the Council for Affordable Quality Healthcare (CAQH), Credentialing System and proprietary claim systems.

8.Manages audit preparation of materials and files necessary to comply with external audits by payors and/or governmental agencies.

9.Conduct audits of the credentialing database and provider directory, confirming accurate input of provider data, and verifying accuracy of modifications made to the database and downstream impacts to other reporting tools and functions.

10. Responsible for the delegated credentialing process and relationship with delegated entity.

11. Identifies and resolves technical, operational and organization problems outside own team.

12. Independently resolve issues and to develop solutions for existing problems to be escalated to internal leadership where appropriate.

13. Plans, implements, manages, and oversees projects for Credentialing and Provider Data Management, to include new system implementation, mailings, notifications, etc.

14. Provides leadership and direction to professional staff and maintains a professional working relationship with all staff, always responds to staff concerns in a professional and timely manner; maintains appropriate interdepartmental communication

15. Participates in discussions regarding project-related decisions and project direction at the executive or senior staff level as needed and appropriate.

16. Provide assistance processing credentialing applications and provider data updates/changes as needed.

PHYSICAL REQUIREMENTS: The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.Working on a computer

2.Sitting for long periods of time

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1.Remote work location.

SKILLS AND ABILITIES:

Strong collaboration, teambuilding, and consensus building skills required

Demonstrated leadership and organizational skills

High-level problem identification/mitigation/resolution skills

Ability to balance multiple projects/tasks

Ability to work with internal and external stakeholders to accomplish goals

Proficiency with Microsoft Office (Excel, Word, PowerPoint)

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

PHH Peak Health Holdings

Cost Center:

2901 PHH Provider Management