What are the responsibilities and job description for the Credentialing Manager position at AP Rochester?
Calling all Upstate NY health credentialing professionals! Do you want to work remotely for a well-established, supportive and fun organization? AP Professionals has been retained exclusively in search of a Credentialing Manager. This redesigned position is responsible for managing systems, processes, employee supervision, and contractor oversight. It also ensures accuracy, adherence to organizational policies, and compliance with the requirements of health plan partners and local, state, and federal regulations.
The ideal candidate will be a proactive leader with a strong knowledge of medical credentialing and auditing, excellent presentation skills and be committed to the organization's mission.
Preference for candidates that live in New York State.
Responsibilities
Hire, train, supervise, and direct Credentialing, Auditing, and Coding staff, ensuring work allocation, adherence to policies, and effective problem resolution.
Collaborate with Revenue Cycle Leadership to establish policies and procedures for auditing, payer enrollment, and credentialing.
Develop project plans for Credentialing and Auditing, providing quarterly updates to Compliance and Risk Management teams.
Support contract negotiations, evaluate third-party payer agreements, and address medical claim denials to mitigate risks and optimize revenue.
Stay informed on changes to laws and regulations affecting Credentialing and Coding to identify risks and ensure compliance.
Oversee provider and facility credentialing with health insurance carriers, ensuring compliance with Federal, State, and payer guidelines.
Collaborate with Clinical Services and HR to streamline credentialing data collection and processes.
Maintain accurate credentialing records, ensuring timely revalidation and adherence to accreditation standards.
Build relationships with payer representatives to enhance provider enrollment and contractual alignment.
Oversee coding and documentation training for medical providers.
Manage and analyze quarterly coding and documentation audits, identifying trends and implementing corrective actions to improve compliance and revenue.
Collaborate with Clinical and Revenue Cycle Leadership to enhance provider documentation, charge review, and claim scrubbing processes.
Ensure compliance with Federal, State, and payer standards for chart documentation and medical necessity.
Stay updated on CPT and ICD guidelines.
Provide coding and compliance guidance for new or updated services.
Supervise and assist with internal and external audits.
Foster a respectful, customer-oriented, and inclusive work environment.
Perform additional duties as assigned.
Education
Bachelor’s degree or equivalent experience in business, public health, or related field.
Certified Professional Coder or Certified Professional Medical Auditor, preferred.
Notary Public Certification, preferred.
Experience
At least 3 years of experience in credentialing and auditing.
At least 3 years of supervisory experience including hiring, training, and evaluation.
At least 2 years of experience designing and delivering professional training, including formal and informal presentations to diverse audiences.
Knowledge, Skills, Abilities, and Other Characteristics
Comprehensive knowledge of medical credentialing, coding, documentation, auditing, and the healthcare environment.
Proficient in data analysis, drawing conclusions, addressing inquiries from providers and payers, and delivering impactful presentations.
Excellent verbal and written communication skills.
Experience with electronic practice management and electronic health records systems; NextGen experience preferred.
Advanced proficiency in Excel and other MS Office applications.
Strong interpersonal skills to promote a collaborative team environment.
Flexible schedule with the ability to travel to multiple sites as needed.
Reliable transportation and / or a valid driver’s license in good standing.
Commitment to respecting and learning about cultural differences, historical traumas, and intersectionality among colleagues, clients, and vendors.
Multilingual candidates are highly encouraged to apply.
Ability to travel to all agency locations as required.
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