CREDENTIALING MANAGER

The Credentialing Manager is responsible for overseeing all aspects of credentialing and recredentialing of health care professionals and ensuring compliance for the medical practice. This position ensures all health care professionals are appropriately credentialed, which includes the responsibility of maintaining current information on file and within the credentialing database, as well as hospital privileging of providers.

Essential Functions

• Completion of health care professionals credentialing and re-credentialing applications.
• Data entry of new applications in the credentialing database.
• Maintain working knowledge of the National Committee on Quality Assurance (NCQA) standards and State and Federal regulations related to credentialing.
• Perform and collect 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.
• Maintain the credentialing database and ensure up-to-date information is obtained at all times.
• Responsible for monitoring and managing credentialing/re-credentialing requirements and to ensure the collection of all required renewal certifications are on file within the required time frame.
• Provide consistent and timely follow-up on all outstanding credentialing/re-credentialing files.
• Prepare and scan credentialing/re-credentialing files and other credentialing documentation into scanning software.
• Prepare credential reports and any adverse action documentation.
• Provide support to physicians, physician office staff, health plan contacts and company departments as necessary.
• Oversee the hospital privileges process for providers.
• Process provider demographic changes ensuring appropriate documentation has been submitted with the changes, update credentialing database and notify health plans of changes.
• Process provider network terminations, specialty/category changes, leave of absence requests.
• Prepare for and assist with credentialing audits.
• Comply with HIPAA and Corporate Compliance program policies and other applicable corporate and departmental policies.
• Maintain privacy and confidentiality.
• Perform other related duties as assigned.

Competencies

• Must demonstrate exceptional communication skills, listening effectively and asking questions when clarification is needed.
• Ability to plan and prioritize work to meet goals, objectives, and deadlines.
• Demonstrate accuracy, organizational and problem-solving skills. Look for ways to improve and promote quality and monitors own work to ensure quality is met.
• Maintain confidentiality.
• Ability to assume responsibility and exercise good judgement in making decisions within the scope of authority of the position.
• Must demonstrate and promote a positive team-oriented environment.
• Must be able to stay focused and concentrate under normal or heavy distractions.
• Must possess ability to manage change, delays, or unexpected events appropriately.

Physical requirements

• Sitting for approximately 90% percent of the day
• Periods of walking, standing, bending, lifting, and reaching
• Fine motor skills
• Visual acuity

Required education and experience

• Minimum of six (6) years credentialing experience.
• Ability to obtain Certified Professional Medical Services Management (CPMSM) certification within six months of employment.
• Experience with provider credentialing software and databases.
• Working knowledge of credentialing accreditation regulations, policies and procedures, and NCQA standards.
• Health plan experience.

Preferred education and experience

• Two (2) years of supervisory or management level experience in credentialing.