Under the general supervision of the Director of Contracts Management, the Credentialing Administrator is responsible for the credentialing and re-credentialing of all providers in the Detroit Wayne Integrated Health Network.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Oversees the credentialing and re-credentialing of all providers in the Detroit Wayne Integrated Health Network.
• Organizes new provider documentation and credentialing information and manages credentialing information requests to ensure compliance with credentialing policies and procedures.
• Tracks provider certifications and licensure expiration dates and ensures that all healthcare providers maintain current credentials and are in compliance with regulatory standards.
• Initiates and coordinates the acquisition and receipt of all credentialing documentation for new providers; provides follow-up and problem resolution as required.
• Coordinates re-credentialing for all physicians and allied health practitioners to ensure no lapse of coverage for facility privileges or health plan in-network status.
• Maintains the credentialing database and ensures up-to-date information is obtained.
• Monitors and manages credentialing/re-credentialing requirements to ensure the collection of all required renewal certifications are on file within the required time frame.
• Collects information from the National Practitioner Data Bank (NPDB), the applicant and their malpractice insurer, and other relevant sources.
• Identifies discrepancies in information and investigates said discrepancies.
• Tracks the expiration of certifications to maintain up-to-date files.
• Screens practitioners' applications and supporting documentation to ascertain their eligibility.
• Performs and collects PSV (primary source verification) documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on NCQA standards, health plan requirements and company credentialing policies.
• Audits Michigan Disciplinary reports, OIG reports, and other reports as required and initiates the formal complaint procedure when applicable.
• Provides consistent and timely follow-up on all outstanding credentialing/re-credentialing files.
• Prepares credential committee grids and any adverse action documentation.
• Presents applications to the Credentialing Committee.
• Monitors license renewal for all applicable providers.
• Acts as primary point of contact for all internal and external customers associated with credentialing.
• Supervises staff within the credentialing department to ensure timely resolution of all tasks.
• Develops and maintains written operational policies and procedures to ensure consistent processes throughout the credentialing cycle.
• Researches health plan credentialing requirements to ensure that all providers are compliant with submission of credentialing material.
• Communicates with internal customers to ensure that start dates of new practitioners are in alignment with credentialing status.
• Assists Credentialing Committee Medical Director based on established guidelines and committee meeting follow-up.
• Provides technical support and guidance to team members and educates team members on guidelines and procedures.
• Assists customers with credentialing inquiries.
• Responds to health plan provider inquiries.
• Performs related duties as assigned.

KNOWLEDGES, SKILLS, AND ABILITIES:

• Knowledge of DWIHN policies, procedures, and practices.
• Knowledge of the DWIHN provider network and community resources.
• Knowledge of the Michigan Mental Health Code.
• Knowledge of MDHHS policies, rules, regulations, and procedures.
• Knowledge of Federal policies, rules, regulations, and procedures as it relates to DWIHN.
• Knowledge of behavioral health and mental health principles and practices.
• Knowledge of the Michigan Medicaid Provider Manual.
• Knowledge of Credentialing policies and procedures.
• Knowledge of NCQA requirements and the accreditation process.

• Knowledge of contracting policies and procedures.
• Knowledge of Compliance rules and regulations.
• Supervisory skills.
• Management skills.
• Training skills.
• Assessment skills.
• Evaluation skills.
• Organizational skills.
• Planning skills.
• Report writing skills.
• Decision Making skills.
• Critical Thinking skills.
• Presentation skills.
• Interpersonal skills.
• Communication skills.
• Written communication skills.
• Accuracy and detailed oriented skills.
• Computer skills (Word, Excel, Access, Power Point, Outlook, Teams).
• Teamwork skills.
• Research skills.
• Investigation skills.
• Ability to communicate orally.
• Ability to communicate in writing.
• Ability to work effectively with others.
• Ability to work with an ethnically, linguistically, culturally, economically, and socially diverse population.
• Judgement/Reasoning ability.

REQUIRED EDUCATION:

A Bachelor’s Degree from a recognized college or university in a Human Service, Social Service, Public Health, Public Administration, Healthcare Administration, Health Management, Business Administration, Psychology, Counseling, Social Work, or a related field.

REQUIRED EXPERIENCE:

• Five (5) years of full-time paid professional experience working in a human service, social service, mental health, or behavioral health setting.

AND

• Three (3) years of full-time paid professional experience performing Credentialing duties and responsibilities.

AND

• Two (2) years of full-time paid professional experience as an executive, administrator, manager or supervisor in a human service, social service, mental health, or behavioral health setting.

REQUIRED LICENSE(S).

A valid State of Michigan Driver’s License with a safe and acceptable driving record.

WORKING CONDITIONS :

Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval. Currently this position is primarily a remote position.

This description is not intended to be a complete statement of job content, rather to act as a general description of the essential functions performed. Management retains the discretion to add or change the position at any time.

Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.

The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer