QUALIFICATIONS & EXPERIENCE REQUIREMENTS

• Minimum of 3 years secretarial experience required (preferably in a healthcare setting).
• Credentialing experience in a managed care setting strongly desired.
• Intermediate level familiarity with medical terminology, NCQA guidelines, federal contracting requirements, long-term care licensure and certifications desired.

KNOWLEDGE/SKILLS/ABILITIES

• Intermediate level ability using Microsoft Office Suite (Word, Excel, PowerPoint, Access). Familiarity with Lotus Notes a plus.
• Intermediate ability to circumnavigate internet to achieve online research requirements as necessary
• Excellent oral and written communication skills are required.
• Ability to multitask and work independently under strict deadlines with minimal supervision is required.
• Ability to work confidentially is a must.
• Considerable interpersonal skills, including the ability to establish and maintain effective working relationships internally and externally.

PURPOSE/BELIEF STATEMENT

The Credentialing Manager performs and manages credentialing and recredentialing in compliance with federal, state and NCQA requirements and guidelines. The Credentialing Manager role is primarily to ensure the timely and accurate submission of credentialing information to contracted Insurance Payors in order to establish and/or maintain continued participation in Insurance Payors’ networks. The Credentialing Manager is also designated by the company CFO to manage all company/facility registrations within the Dun & Bradstreet and SAM.gov federal contracting database where credentialing is concerned.

JOB DUTIES & RESPONSIBILITIES

• Receive initial credentialing, re-credentialing and facility addition requests from a variety of sources including but not limited to Health Plans, Government Contractors, Facilities and Facility Administrators, CPAN and MNS.
• Record requests and progress in a tracking database or other tool
• Review requests for new contracts with the Corporate Director of Managed Care for approval of inclusion in a new contract
• Interact with a variety of departments and agencies to address issues and obtain guidance, documentation and/or clarifications: including but not limited to company ownership, legal counsel, risk management department, licensing and regulatory agencies, both internal and external to CHS.
• Act as a resource to facilities, Corporate Director of Managed Care and others for troubleshooting managed care questions and concerns including, but not limited to claims submission difficulty, W9 functionality as specifically related to company structure, credentialing protocol, etc.
• Complete applications and assemble documentation as required by the Health Plan or other entity within specific deadlines established by the Health Plan and maintain copies for reference
• Follow through on delivery and acceptance of supplied material
• Obtain and confirm network participation status with Health Plan or entity once completed
• Communicate with originators of requests, as well as other affected parties to provide timely status updates.
• Maintains current files of supporting documents electronic or otherwise to reduce burden of submission on facilities.
• Performs initial, triennial and focus credentialing and re-credentialing activities for MCOs as assigned
• Participate with and report credentialing activities to Corporate Director of Managed Care
• Participates in development of policies, procedures, workflows and tools.
• Network with provider organizations.
• Contributes to the team effort by accomplishing related results as needed within specified timelines.
• Assist in ongoing training and education of facilities.
• Responsible for adding and deleting organizations from company structure, editing and revising all aspects of registrations with Dun & Bradstreet and SAM.gov federal database, authorizing all companies to do business with third party payors and any associated documents that are necessary to facilitate the coordination of credentialing.
• Works closely with contract manager, tax accountant and CFO to assure accurate completion
• Professional Development
• Maintains awareness of professionalism and maintains the utmost confidentiality of information gathered and supplied.
• Maintains professional competence through continuing education.
• Demonstrates the ability to multitask and work independently with minimal supervision.
• Excellent written and oral communication skills demonstrated.
• Perform Other Related Duties As Required Or Assigned
• Act as backup for the Columbus Regional Office Executive Assistant.
• Assist with handling of office duties in the absence of the EA or when multiple meetings are scheduled that require assistance
• Other duties as assigned