Mgr, Credentialing

Responsibilities

• Lead Credentialing Team day to day activities while planning / executing for long-term growth
• Mentor, develop, and train team members as well as educate the PDS team or field team members (affiliated clinical and operational) on the carrier and plan credentialing nuances
• Ensure and maintain PDS compliance with all doctor’s credentials and licenses
• Manage the credentialing process in accordance with NCQA, CMS, federal and state laws/standards
• Develop and provide reporting and subject matter expertise to field and PDS team members including status reports, out-of-network reporting, re-credentialing updates, etc.
• Develop and provide reporting to measure the throughput of the credentialing team, ensure timeliness and accuracy of all credentialing processes, and gap analysis for improvement
• Partner with the billing department and Epic team to ensure all credentials are loaded timely
• Establish and build relationships as the primary point of contact with insurance plan representatives
• Analyze insurance plan trends that may impact the business (e.g., credentialing alternatives and competitors, the potential impact of the Affordable Care Act, etc.). Make recommendations to optimize the credentialing process
• Facilitate the credentialing team’s coordination and communication with the onboarding of new doctors and all departments, including Legal, People Services, DeNovo, and field leadership
• Collaborate with billing and patient relations departments on denials, downgrades, or other anomalies to align billing practices with insurance carrier requirements that improve care and reduce overall cost
• Oversee the development and maintenance of training programs, manuals, and all field/clinician-facing collateral
• Lead/coordinate projects and special assignments as required by planning and identifying opportunities for process improvement/efficiency
• Ensure alignment with the maintenance of audit procedures, including process adherence, document tracking, records, reports, policies, and procedures for accuracy and effectiveness
• Other duties as assigned by management

Qualifications

• Bachelor’s Degree or one-year certificate from an accredited college or technical school; or equivalent combination of education and experience, and 4-6 years of related business experience
• In lieu of education, 8+ years of experience is required
• Experience in assessing workflow, leading a team, mentoring, coaching, and training subordinate
• Preferred Experience in a multi-regional healthcare, retail, or dental company
• Credentialing leadership with proven results
• Knowledge/Skills/Abilities: Strong abilities in managing the daily operations of department(s) or work unit while developing short to medium term (1-3 years) goals; Fostering employee development by providing a supportive learning environment; Highly developed teambuilding, influencing, and collaboration skills; Ability to direct the work of others and work as a team leader in attainment of goals; Ability to interpret and apply policies and procedures; Ability to handle and maintain extreme confidentially with employee records, compensation information, etc.; Ability to draw valid conclusions; apply sound judgment in making decisions, and make decisions under pressure; Proficient communication skills with a commitment to achieving predetermined goals; Read, analyze, and interpret documents such as professionals journals, technical procedure manuals, safety rules, operating and maintenance instructions, and governmental regulations; Ability to interpret a variety of instructions furnished in written, verbal or diagram form

Pay

$93,000.00 - $117,000.00 / Annually

Schedule

N/A

Benefits

• Medical, dental, and vision insurance
• Paid time off
• Tuition Reimbursement
• 401K
• Paid time to volunteer in your local community

Company Info

PDS Health is an Equal Opportunity Employer. We celebrate diversity and are united in our mission to create healthier and happier team members.