National Director, Credentialing & Provider Enrollment
Steward Health Care Network (SHCN) takes pride in its community-based care model, which drives value-added tools and services to our communities, patients, physicians, and hospitals across the continuum of care. In addition, Steward Health Care Network promotes care coordination and collaboration within the network in order to provide high-quality, efficient care to patients. With Steward in the community, all residents can be sure that there is a world-class doctor close to where they live.
The network is also responsible for the implementation and execution of our managed care contracts, medical management services, quality improvement programs, data analysis, and information services.
Position Purpose: This position interfaces and partners with the Quality Management and Performance Leadership teams and cross functional business partners to provide expertise in enrollment, credentialing, and recredentialing of SHCN providers in alignment with NCQA standards. The position acts as a liaison between SHCN and our Providers and manages the Credentialing and Provider Enrollment teams.
- Oversee all aspects of the credentialing/recredentialing of practitioners in alignment with NCQA standards and enrollment of SHCN providers into health plan contracts. Assure compliance with State, Federal, and national regulatory standards. Also responsible for pre-delegated and annual audits of all credentialing delegated entities. Manage all activities and ensure quality related to credentialing operations and payer enrollment and provide oversight to ensure the continued growth and development of the organization
- Responsible for annual quality improvement reports. Prepare credentials files for presentation to committees, payers, and clients within established deadlines or appoint designee. Support Credentialing and Quality meetings on an ongoing basis; coordinating meeting times, schedules, developing agenda and presenting necessary documents for review with the respective committees. Develop close and collaborative working relationships with provider and local chapter offices to streamline the accurate submission of information to the health plans and to SHCN. Work closely with SHCN, its affiliates, SMG, and the health plans to reconcile any differences in listings of enrolled SHCN physicians
- Train and mentor members of the team. Act as a liaison between SHCN and our Providers. Educate and effectively work with the credentialing and provider enrollment teams, as well as clinicians to facilitate a seamless credentialing and provider enrollment experience. Collaborate with and maintain open communication with all departments to ensure effective and efficient workflow and facilitate completion of tasks/goals
- Ensure compliance with regulations and contractual obligations. Effectively use financial information for strategic and operational decision making, participate in the preparation of annual budgets, and monitor performance to budget and meet agreed upon metrics
- Track/manage/report on the network composition on a monthly (and on an ad hoc) basis. Produce reports indicating the number of primary care providers and specialists by chapter, by state, by region. Produce reports related to network development trends
- Leads the charge in focus and implementation of the organization's culture and strategic plan in a way that aligns to the mission, vision, and values of the organization
Education / Experience / Other Requirements
- Bachelor’s degree required
- Master’s degree strongly preferred
Years of Experience:
- A minimum of six (6) years health care quality focused roles
- 7+ years in credentialing and provider enrollment. Clear advancement in responsibilities and outputs is preferred
- Expertise with Microsoft Office software (Word, Access, Excel, PowerPoint), and experience with Credentialing systems
- Previous Managed Care and/or Medicaid experience strongly preferred
- Strong analytic skills and the ability to translate complicated data into useable information, including analysis of practice variation
- Demonstrated organizational and project management skills to manage complex projects through effective planning, tracking, and resource allocation to meet business objectives and timelines
- Strong leadership and management skills. Knowledge of methods used for improving employee performance/motivation
- Ability to generate creative solutions, identify the best course of action and rapidly resolve complex issues/problems
- Skill in resolving employee/customer conflicts and complaints in a mutually satisfactory way
- Ability to communicate clearly with employees at all organizational levels, and across differing cultural backgrounds
- Thorough understanding of managed care principles and physician practice operations, with an understanding of health plan provider enrollment and credentialing
- 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
Steward Health Care is an Equal Employment Opportunity (EEO) employer. Steward Health Care does not discriminate on the grounds of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity and/or expression or any other non-job-related characteristic.
Steward Health Care Network is taking additional, necessary preparations to ensure patients can receive compassionate care in a safe, carefully managed environment – with confidence and without fear.
Our Safe and Ready program consists of a rigorous [three-point] standard ensuring patient safety, confidence and convenience:
- Any COVID-19 related care takes place in designated areas away from other patients and their families.
- A stringent cleaning policy has been implemented throughout our facilities.
- A strictly controlled visitor and masking policy is required for patient and colleague safety.
You can rest assured that we have made the necessary preparations to provide care in a safe, controlled and professional way.