Director of Credentialing and Provider Maintenance

Job Summary

Reporting to the Executive Director Network Management & Cost of Care, the Director, Credentialing and Provider Data Management is responsible for all credentialing and provider data management activities for Medicaid, Medicare, Commercial and Tricare lines of business. The Director assures that all Credentialing activities are performed within the credentialing specifications of National Committee for Quality Assurance (NCQA) guidelines, Code of Maryland Regulation (COMAR), QLARANT and US Family Health Plan (USFHP) Tricare regulations. This position also ensures credentialing practices are also consistent with industry practice standards. The Director is also responsible for the overall completeness and accuracy of provider data as well as entry into provider data management systems. The Director develops and implements policies and procedures to guide all credentialing and provider maintenance activities.

Role Accountabilities Include

• Ensures compliance with all relevant regulations and industry standards pertaining to provider data management and credentialing/re-credentialing

• Assumes ownership of the provider directory for all lines of business to ensure compliance with regulatory agencies including NCQA accreditation.

• Serves as the business owner of our provider data management strategies in collaboration with Information Technology and Provider Relations.

• Works collaboratively with IT to identify and implement enhanced systems and processes for onboarding, updates, and network monitoring to ensure efficiency and accuracy.

• Ensure timely and accurate data and data governance are implemented and streamlined.

• Works collaboratively with provider relations and provider enrollment teams to prioritize and successfully implement geographic expansion or other special projects related to credentialing or provider maintenance.

• Oversees the delegated credentialing organizations to ensure agreements are updated and executed upon timely and that JHHP receives timely and accurate information for provider enrollment and changes to demographic information.

• Serves as the network’s subject matter expert on credentialing standards including NCQA along with federal and state regulations; maintains current knowledge of industry standards and best practices

• Oversee the timeliness, accuracy, and completeness of all provider data and credentialing activities

• Oversight and management of Provider Maintenance and Credentialing vendors by setting priorities, handling escalations and verifying SLA’s are met.

Qualifications:

• A Bachelor’s Degree in Business Administration/Management or related discipline is required. Post graduate degree strongly preferred.

• Credentialing certification preferred - Lean Six Sigma Certification (e.g., green belt, black belt, master black belt or other) preferred

• At least 7-10 years of experience in a managed-care health plan environment, with experience in provider maintenance and credentialing including at least 3-5 years of management experience is required. Experience in basic data collection, compilation and reporting is necessary. Understanding and use of basic reporting tools such as SQL and Excel are required.

Many organizations talk about transforming the future of healthcare, at Johns Hopkins Health Plans, we are setting the pace for change within the healthcare industry. We develop innovative, analytics-driven health programs in collaboration with provider partners to drive improved quality and better health outcomes for our members and the communities we serve. If you are interested in improving how healthcare is delivered, and have a passion to be at the forefront of change, JHHP is the place to call home.

Please note: US citizenship is required for this position as it falls under the terms of a government contract (to ensure compliance with DODPSP).