POSITION DESCRIPTION

As the Credentialing & Enrollment Manager, your role involves leading the function of Credentialing and Enrollment at Eleanor. In this role, you will lead internal credentialing, and manage organization and completion of licensing and enrollment. It is your responsibility to ensure that internal credentialing and enrollment workflows are in compliance with state, federal, and accreditation bodies’ standards and reflection of EH core values. This role will collaborate and directly report to the Senior Director of Clinical Quality & Care Model and provide assistance to colleagues, departments, and clinics as needed.
It is important that this role is held by an individual who can serve as a subject matter expert in credentialing and enrollment standards and is enthusiastic about organizing and managing the transfer and completion of tasks.
This role will involve conducting regular qualitative and quantitative reviews of both internal and external workflows and ensuring adherence to our internal policies and procedures. This role is responsible for developing and executing both short-term and long-term projects aimed at enhancing the quality and efficiency of care provided to Eleanor’s community members.

QUALIFICATIONS

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• At least three years of experience in healthcare credentialing and enrollment management.

• Have experience with cross-market licensing and enrollments.
• Have expertise in current NCQA standards.
• You are passionate about working with our payer partners, CVO, and internal stakeholders to improve TAT’s/KPI’s.
• Have experience serving on interdisciplinary teams and enjoy working in a collaborative environment
• Enjoy finding opportunities to improve, developing solutions, and communicating those opportunities to peers & leaders in an actionable and collaborative way
• Enjoy meeting new people and establishing mutually beneficial working relationships

Specifically you will:

• Serve as a subject matter expert on which Eleanor Health providers hold an individual license in a specific market, are internally credentialed, and are successfully enrolled with all payer partners for their associated markets
• Manage the sources of truth that hold/organize this information
• Communicate this information to stakeholders effectively

• Partner with Sr. Director of CQCM to inform C&E KPIs and strategy

• • Proactively assess and report resource barriers and/or support needed to meet internal and external timelines
• Analysis of vendors, options, implementation plan, and expectations
• Serve as a collaborative partner with internal department leaders
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• People Team

• Staff Development (Operations, Learning & Development)
• Serve as a supervisor and manager to C&E specialists
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• Responsible for maintenance of job descriptions, scorecards, performance reviews, PTO, etc.

• Build and maintain relationship with external partners and payers
• Manage the completion and expiration of internal credentialing applications
• Manage Enrollment rosters for delegated payers & review enrollment rosters for non-delegated payers- track expirations
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• Disseminate rosters on a monthly basis and communicate with payer as needed

• Manage Audits with delegated payer partners.
• Manage and facilitate communication with external Licensing and Enrollment third-party vendor
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• Build relationship with team leads and customer success representative

• Communicate priorities and expectations
• Track completion of tasks, compare with estimates/expectations
• Track barriers and opportunities for performance improvement
• Provide feedback and address barriers
• Manage and ensure accuracy of project management boards owned by C&E
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• Licensing source of truth

• Internal Credentialing source of truth
• Enrollment source of truth
• Coordinate with the Revenue Cycle Management team to
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• Triage questions related to licensing, credentialing and enrollment of internal teammates

• Assist in the resolution of denied claims
• Communicate with payers on questions or barriers in information
• Payor portal management
• Monitoring the accuracy and efficiency of the internal policies:
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• 1.I.4.a (2) Credentialing Policy & Procedure

• 1.I.10. Workforce Education, Training and Credentials Process
• Support onboarding of staff
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• Begin internal credentialing process

• Add provider into enrollment priority
• Add provider into licensing priority if needed
• Support offboarding of staff
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• Removal from payor registries/rosters

• Marking staff as inactive in sources of truth for licensing, credentialing & enrollment
• Other responsibilities and tasks as needed and assigned