Regional Manager of Credentialing and Auditing

Description

Planned Parenthood of Central and Western New York (PPCWNY) protects and provides health care and education that empowers individuals and families. With respect. Without judgment. No matter what.

Diversity and inclusion are core values at Planned Parenthood of Central and Western New York (PPCWNY). PPCWNY recruits exceptional and diverse staff. PPCWNY strives to develop staff into leaders for a diverse and global workplace.

In support of Planned Parenthood of Central and Western New York (PPCWNY)’s mission, the Regional Manager of Credentialing and Auditing is accountable for systems, processes, management and supervision of employees and oversight of contractors for Credentialing and Auditing to ensure accuracy and adherence with organizational policies and procedures, and compliance with requirements of our health plan partners and local, State, and Federal regulatory agencies.

The Regional Manager of Credentialing and Auditing will stay informed of industry trends and regulatory requirements including ICD/CPT codes, Medicare and Medicaid regulations as well as having a clear understanding of laws impacting utilization management of credentialing for government health plans as well as auditing principals and reporting processes.

Works collaboratively with Revenue Cycle Leadership and Health Services Leadership, providing support direction, and research findings to develop policies and standardized processes for Credentialing and Auditing.

• Responsible for the hiring, training, direction and supervision of the Coding, Auditing and Credentialing staff including work allocation, training, and enforcement of internal procedures and controls, and problem resolution.
• Works collaboratively with Revenue Cycle Leadership to create policies and procedures for auditing, payer enrollment and credentialing.
• Develops project plans for Credentialing and Auditing, and reports quarterly to Shared Service Affiliates Compliance and Risk Management departments on the associated measures.
• Assists and supports Revenue Cycle Leadership and/or our contracted vendor with Payer contract negotiations of terms and conditions with payers to ensure favorable agreements with shared service affiliates.
• Engages in proposed revision of Third-Party payer contracts and/or consideration of new payer contracts as appropriate to meet affiliate fiscal interests.
• Works collaboratively with Revenue Cycle Leadership to evaluate Third-Party payer contracts; investigates and resolves medical claim denials related to Enrollment Credentialing, Coding, or other Payer issues to mitigate risk and optimize revenue growth.
• Stays current on changing laws and regulations related to Credentialing and Coding and identifies potential risks.

Credentialing

• Coordinates all aspects of individual provider and facility participation with health insurance carriers under their respective delegated credentialing agreements.
• Works collaboratively with Clinical Services and Human Resources to develop and implement seamless protocols for gathering Credentialing data from Providers, including expediting completion of forms, obtaining signatures, and locating required documentation.
• Interprets, communicates, and implements policies and procedures to ensure that applications are properly verified and accurately uploaded to credentialing database systems with adherence to applicable Federal, State, and/or Payer guidelines.
• Supervises the management and functions of Credentialing staff and/or contracted personnel to ensure all Shared Services Affiliate Providers are enrolled, credentialed, and revalidated timely with Medicaid, Medicare, and all contracted Third-Party Payers in accordance with guidelines set forth in the Credentials Verification Organization (CVO) policy and accreditation standards for Planned Parenthood Federation of America (PPFA).
• Develops and maintains relationships with payer representatives through meetings, telephone interactions, and written correspondence to enhance provider enrollment, contractual obligations, and understanding of carrier system workflows and policies.
• Defines and implements processes to maintain accurate and up-to-date Credentialing statuses, renewal requirements and timelines to ensure Credentialing revalidation functions are performed prior to expiration for Providers and with contracted Payers.
• Analyzes data and reports on applications and credentialing status to identify trends and makes recommendations to improve the credentialing processes, contract utilization, and financial outcomes.

Auditing

• Oversees onboarding training for Medical Providers on coding and documentation.
• Oversees staff who perform, analyze, and interpret quarterly Medical Coding & Documentation Audits for all Shared Services Affiliates and their contracted entities.
• Analyzes and investigates results of audits; identifies and reports on trends to determine where change is needed to minimize risks and maximize revenues.
• Develops and presents corrective action plans for audit compliance and comprehensive training for Medical Providers on audit content.
• Collaborates with Clinical Leadership and Revenue Cycle Leadership to define and implement processes to improve the accuracy and efficiency of Provider documentation, effectiveness of charge review and claims scrubbing controls, and mitigate risk to the Affiliate and maximize revenue growth.
• Ensures that provider chart documentation and medical necessity comply with all Federal, State, and payer standards, guidelines, and regulations.
• Monitors internal and external audits that measure Coding Compliance to all applicable standards and regulations.
• Supervises and assists with all external Payer and Regulatory audits.
• Provides guidance on coding and compliance regulations for new and updated services rendered.

Other Accountability Activities

• Maintains current knowledge of CPT and ICD guidelines
• Practices a customer-oriented and team approach in carrying out job responsibilities
• Performs other duties as assigned
• Shows respect to all internal and external customers for differences in backgrounds, lifestyles, viewpoints and needs in areas such as race, gender, ethnicity, creed, sexual orientation, and others

Requirements

Applicants must possess the following qualifications (or equivalent combination of education and experience):

Education—

• Bachelor’s Degree or equivalent experience preferably in a business, public health, or related field
• Certified Professional Coder or Certified Professional Medical Auditor desired
• Notary Public Certification desired

Experience—

• Minimum of three years' experience in Credentialing and Auditing
• Minimum of three years' supervisory experience to include hiring, training, and evaluation
• Minimum of two years’ experience developing and delivering professional trainings, both formal and informal presentations to a variety of audiences

Knowledge, Skills, & Abilities:

• Knowledge of medical credentialing, coding, documentation and auditing, and the healthcare environment in which they operate
• Ability to investigate and analyze data, draw conclusions, respond to questions from providers, payers, and others, and deliver effective presentations
• Must have excellent communication skills (verbal and written)
• Demonstrated experience with electronic practice management and electronic health records systems is required, NextGen experience is a plus
• Computer skills must include advanced level in Excel and other MS Office programs
• Strong interpersonal skills that foster a cooperative teamwork environment
• Must be able to work a flexible schedule with ability to travel to multiple sites when needed
• Must have reliable transportation and/or a valid driver’s license not in jeopardy of being revoked
• Demonstrates a commitment to respecting and learning about the cultural differences, backgrounds, historical traumas, and intersectionality of all colleagues, clients, customers, and vendors
• Planned Parenthood seeks candidates who are proficient in two or more languages

Physical Requirements

• Possess sufficient mobility to perform the Essential Functions listed in this Job Description with or without an accommodation
• Ability to travel to all agency locations as assigned

Salary : $68,536 - $79,352