Steward Health Care Network
Steward Health Care Network
Position Purpose: Reporting to the Credentialing & Provider Enrollment Director, the Credentialing Manager coordinates the accurate and efficient Credentialing and Recredentialing of SHCN providers in alignment with State, Federal, and NCQA standards.
Responsible for managing, organizing, and coordinating all aspects of the Credentialing and Recredentialing activities for practitioners and organizational providers in accordance to credentialing standards and guidelines. Responsible for the management of the Credentialing Department: establishing, implementing and monitoring performance goals, metrics, and processes for the Credentialing department. Prepare and maintain various reports, data, and summaries of credentialing activities.
Review and manage provider credentialing processes to ensure that policies/workflows (desktop manuals, policy updates, etc.) are be followed in in compliance with State, Federal, and NCQA guidelines as well as contracted health plan directives. Identifies opportunities for improvements in the process and develops strategies to implement appropriate changes/enhancements; Develop partnerships with relevant internal and external staff; independently troubleshooting issues as they arise.
Accountability for delegated oversight, including performing pre-delegation and annual audits to ensure compliance with the delegated credentialing agreements and regulatory standards. Responsible for coordination and management of the health plan Credentialing Committee(s).
Respond to general inquiries and assist in resolution of administrative and operational issues. Manage staff data entry to maintain database/computerized credentialing system. Prepare and maintain various reports, data, and summaries of credentialing activities. Responsible for administrating and maintaining quality control processes of all Credentialing activities.
Maintain on-going participation in cross-training activities, ensuring appropriate staff training and coverage of incoming volume. Actively engage in addressing special projects as they arise, conducting preliminary research and follow-up, and tracking/monitoring to facilitate on-going reporting of project status. Provides valid feedback to the Credentialing Director on departmental issues and progress. Perform other functions as assigned.
* Bachelor's degree in relevant field (or equivalent combination of education and experience)
Years of Experience:
* A minimum of five years of relevant experience in healthcare related environment, preferably with supervisory experience in a credentialing/recredentialing environment with knowledge of several sets of national accreditation or regulatory criteria.
Work Related Experience:
* Microsoft Office software (Outlook, Word, Access, Excel, PowerPoint), and experience with Credentialing systems.
* Previous Managed Care and/or Medicaid experience strongly preferred.
* Ability to work independently with minimal supervision as the direct manager of this role is located offsite.
* Ability to manage people and work in teams.
* Ability to analyze and evaluate data and other provider related problems in order to develop alternative solutions for a positive outcome.
* Ability to multi-task and prioritize workload, manage multiple priorities, and pay meticulous attention to detail.
* Thorough understanding of managed care principles and physician practice operations, with an understanding of health plan provider enrollment and credentialing preferred.
* Excellent organizational skills, proven project management expertise; Strong verbal and written communication skills.
* Outstanding interpersonal skills, able to quickly establish a trusting rapport with individuals at all levels.
* Requisite poise, judgment, and trustworthiness to represent SHCN to internal and external groups.
* Maintains information in a confidential manner according to policy.
Job Reference #: 53535