Mgr, Credentialing

Description:

Now is the time to join PDS Health. You will have opportunities to learn new skills from our team of experienced professionals. If you're ready to take your career to the next level and gain valuable experience, apply today!

Overview:

The Mgr, Credentialing leads a team responsible for all elements of the Credentialing, Recredentialing, and/or Delegated Credentialing processes. The Mgr, Credentialing will ensure ongoing execution of credentialing and other applicable provider onboarding functions completed are in accordance with applicable department policies and procedures.

Responsibilities

Lead Credentialing Team day to day activities while planning / executing for long-term growth

Mentor, develop, and train team members as well as educate the PDS team or field team members (affiliated clinical and operational) on the carrier and plan credentialing nuances

Ensure and maintain PDS compliance with all doctor’s credentials and licenses

Manage the credentialing process in accordance with NCQA, CMS, federal and state laws/standards

Develop and provide reporting and subject matter expertise to field and PDS team members including status reports, out-of-network reporting, re-credentialing updates, etc.

Develop and provide reporting to measure the throughput of the credentialing team, ensure timeliness and accuracy of all credentialing processes, and gap analysis for improvement

Partner with the billing department and Epic team to ensure all credentials are loaded timely

Establish and build relationships as the primary point of contact with insurance plan representatives

Analyze insurance plan trends that may impact the business (e.g., credentialing alternatives and competitors, the potential impact of the Affordable Care Act, etc.). make recommendations to optimize the credentialing process

Facilitate the credentialing team’s coordination and communication with the onboarding of new doctors and all departments, including Legal, People Services, DeNovo, and field leadership

Collaborate with billing and patient relations departments on denials, downgrades, or other anomalies to align billing practices with insurance carrier requirements that improve care and reduce overall cost

Oversee the development and maintenance of training programs, manuals, and all field/clinician-facing collateral

Lead/coordinate projects and special assignments as required by planning and identifying opportunities for process improvement/efficiency

Ensure alignment with the maintenance of audit procedures, including process adherence, document tracking, records, reports, policies, and procedures for accuracy and effectiveness

Other duties as assigned by management

Qualifications

Bachelor’s Degree or one-year certificate from an accredited college or technical school; or equivalent combination of education and experience, and 4-6 years of related business experience. In lieu of education, 8+ years of experience is required

Experience in assessing workflow, leading a team, mentoring, coaching, and training subordinate

Preferred

Experience in a multi-regional healthcare, retail, or dental company

Credentialing leadership with proven results

Knowledge/Skills/Abilities

Strong abilities in managing the daily operations of department(s) or work unit while developing short to medium term (1-3 years) goals

Fostering employee development by providing a supportive learning environment

Highly developed teambuilding, influencing, and collaboration skills

Ability to direct the work of others and work as a team leader in attainment of goals

Ability to interpret and apply policies and procedures

Ability to handle and maintain extreme confidentially with employee records, compensation information, etc.

Ability to draw valid conclusions; apply sound judgment in making decisions, and make decisions under pressure

Proficient communication skills with a commitment to achieving predetermined goals

Ability to read, analyze, and interpret documents such as professionals journals, technical procedure manuals, safety rules, operating and maintenance instructions, and governmental regulations

Ability to interpret a variety of instructions furnished in written, verbal or diagram form

Benefits

Medical, dental, and vision insurance

Paid time off

Tuition Reimbursement

401K

Paid time to volunteer in your local community

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Salary Information: $93,000.00-$117,000.00 / Annually