Credentialing Manager

POSITION OVERVIEW:        

Under the supervision of the Vice President of Human Resources the Credentialing Manager is responsible for managing credentialing and privileging functions network-wide.  The Credentialing Manager will workflows to ensure compliance with all regulatory agency requirements. This position requires maintaining knowledge of all updates to HRSA, OASAS, TJC, DOH, Federal and NYS guidelines pertaining to credentialing and privileging.

KEY ESSENTIAL FUNCTIONS:                                                                                                             

• Responsible for the credentialing and privileging of all employed/contracted licensed independent practitioners and other licensed/certified healthcare providers for all entities under Acacia Network.  
• Develop an annual credentialing compliance work plan including a risk assessment of the processes.
• Develop, initiate, maintain and update policies, protocols and forms for credentialing/privileging aspects of the program to ensure quality care, continued accreditation and/or designations.
• Drive implementation of day-to-day credentialing compliance controls. Maintain current knowledge of changes in industry rules and regulations and assist in maintaining effective lines of communication with other departments to ensure these changes are disbursed appropriately.
• Process initial/re-credentialing applications and generate credentialing files for all providers. 
• Initiate managed care flow by providing applications and pertinent information to managed care department to begin health plan participation process.
• Identify issues that require additional investigation, validate discrepancies and ensure appropriate follow-up. Prepare credentials file for timely completion and presentation to the Credentials Committee.
• Validate all credentials. Conduct primary source verifications, obtain responses from external sources, and conduct online sanction queries, including NPDB. Conduct monthly monitoring of OIG, OMIG, OPMC, etc.
• Work collaboratively with Managed Care, Office of Legal Affairs and Finance departments to ensure smooth flow of revenue and financial operations. 
• Track and maintain all collaborative agreements and consultant contracts.
• Establish and maintain tracking system to monitor expiring credentials (licensure, malpractice, DEA, boards, hospital privileges, etc.). Notify providers and supervisors of pending expirations. Confirm and verify renewals. Provide managed care with copies to ensure their files are maintained.
• Maintain all annual malpractice certificates of insurance, claims histories/loss runs and explanations. Serve as liaison for insurance brokers. Update and maintain FTCA database.
• Organize and audit credentialing files to maintain systematic compliance with regulatory standards (i.e., TJC, DOH, HRSA, NCQA, OASAS).
• Facilitate credentialing meetings. Work closely with Chief Medical Officer, Executive Senior Management, Risk Management and QA committees towards credentialing committee goals. 
• Proactively prepare for audits. Responsible for credentialing and HR portion of regulatory agency surveys/visits (i.e., HRSA, TJC, DOH, OASAS).
• Responsible for managed care audits. 
• Assist with recruitment efforts, screen resumes and conduct telephone interviews. 
• Manage Relias training system. Update training plans, maintain user licenses, track and report use.
• Assist with developing and revising job descriptions in line with regulatory requirements.
• Monitor goals, objectives and priorities. Accurately complete tasks within established time frames/deadlines.
• Manage multiple projects effectively while facilitating group success. 
• Develop establish, and maintain effective and cooperative working relationships with staff and others contacted in the course of work.
• Analyze interpret a wide range of information, including legal and contract language, policies, standards and guidelines.
• Assist with organization-wide projects. 
• All other duties as assigned by Senior Vice President of HR and Talent Management.

 REQUIREMENTS:                                                                                                                                                  

• HS diploma or GED required, Bachelor’s degree preferred.
• Certified Provider Credentialing Specialist (CPCS) preferred.
• 2 years of supervisory experience is required.
• 5 years of credentialing experience is required.
• Strong knowledge of credentialing/privileging procedures and requirements, including managed care process.
• Thorough knowledge of and proficiency with Windows based systems.