As a community, the University of Rochester is defined by a deep commitment to Meliora - Ever Better. Embedded in that ideal are the values we share: equity, leadership, integrity, openness, respect, and accountability. Together, we will set the highest standards for how we treat each other to ensure our community is welcoming to all and is a place where all can thrive.

MINIMUM EDUCATION & EXPERIENCE

• Bachelor’s degree in business or healthcare related field and 5 years of experience in Medical Staff credentialing and/or payer enrollment functions required
• Or equivalent combination of education and experience
• Previous experience with Joint Commission, CMS, and NCQA Regulations related to medical staff services and Commercial Payers Credentialing requiredPrevious management experience preferred

KNOWLEDGE, SKILLS AND ABILITIES

• Excellent interpersonal and communication skills with the ability to develop and maintain relationships with a variety of key stakeholders across the organization preferredDemonstrated success in leading through change while utilizing effective change management tools preferred

RESPONSIBILITIES:

Oversees departmental activities to ensure quality in conducting, maintaining, and communicating the medical and allied health professional staff credentialing, privileging, and primary source verification process. Serves as a leading resource of the department, and collaborates with others to advance the quality of practitioners and patient safety of the facility. Supervises ongoing compliance monitoring. Recruits, hires, supervises and manages the performance of department staff members.

ESSENTIAL FUNCTIONS

• Supervises the timely and accurate completion of health care professionals’ credentialing and re-credentialing applications for internal or external assigned health care organizations, including the primary source verification and collection of documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on Joint Commission and NCQA standards, hospital requirements, and credentialing policies. Ensures the accurate collection and documentation of annual requirements and practitioner privilege requests. Ensures files are completed and securely submitted to the respective entities upon completion, within required timelines, and in accordance with the specific contracts. Sets up internal or external assigned health care organizations with NPDB CC (National Practitioner Databank Continuous Query), monitors statuses, and notifies hospital affiliates and clients of reports. Collaborates with physicians, dentists, and allied health practitioner leaders to develop and maintain a specialty specific, criteria based clinical privileging system in accordance with regulatory requirements, accreditation standards, and organizational policies.
• Ensures the Medical Staff Services department is in compliance with regulatory standards, including but not limited to, The Joint Commission TJC, Center for Medicaid and Medicare Services (CMS), National Committee for Quality Assurance (NCQA), State Department of Health, Occupational Health and Safety Association (OSHA), and other regulatory agencies that govern healthcare. Supervises the ongoing compliance monitoring, including but not limited to, monitoring of health review requirements (OSHA), professional license, DEA, sanctions, NPDB, complaints, and adverse information regarding quality of care. In collaboration with the Payer Enrollment Manager, coordinates the functions related to Delegated Credentialing/Commercial Payer Enrollment Contracts with contracted commercial payers. Represents Medical Staff Office and Credentials Verification Organization (CVO) for regulatory audit/surveys by the JC, NCQA, DOH, CMS, Delegated Commercial Payers, and any other regulatory agency as needed. Collaborates with the UR Contracting Department and Commercial Payers regarding new and existing contracts as they relate to the delegated credentialing functions and reviews contracts for appropriateness. Collaborates with leadership team in the development and maintenance of credentialing policies to ensure the organization is compliant with regulatory standards and all practices are current. Provides education to staff pertaining to medical staff bylaws and credentialing policies and procedures. Collaborates with various national and state leaders and associations. Attends educational seminars and/or conferences to remain current with best practice, evolving standards, technology, and service options available to the industry at large.
• Oversees the Credentials Privilege Review, Committee and Board Approval Process. Supervises the departmental review and recommendation process of credentials files for membership and privileges at multiple affiliate hospitals. Supervises the privileging approval process for Strong Memorial Hospital and Highland Hospital. Manages the department approval process for FPPE/OPPE for Strong Memorial and Highland hospital. Manages the Credentials Privilege and Review Committee Process for the approval of Medical Staff and Allied Health practitioner appointments and privileges at multiple affiliate hospitals. Supervises the weekly expedited Credentials Privilege and Review Committee, Medical Executive, and Board approval process for multiple affiliate hospitals. Supervises the Emergency Privilege process for hospital privileges as needed for all affiliate hospitals.
• Develops and maintains the electronic privileging data and criteria within the credentialing software database. Maintains data within the software system and ensures security is appropriate and limited to the client/hospital affiliate and the staff. Develops, coordinates, and monitors quality initiative activities, including but not limited to, tracking staff performance of file processing accuracy and completion rates. Responsible for ongoing review and assessment of the departmental processes and functions to identify areas in need of improvement and implement changes as needed. Maintains account data to provide accurate reporting on active and historical medical and allied health professional staff. Collaborates with LEAN Performance Improvement Office on various activities within the department and throughout the system as applicable.
• Recruits, hires, manages performance, and supervises qualified staff to accomplish departmental operations and functions. Responsible for thoroughly assessing performance and processes and identifying areas of opportunity for improvement of processes and utilization of resources. Develops and implements tools and policies to support knowledge management, record keeping, and internal and external communication. Collaborates with and assists the director with the overall management and supervision of all Medical Staff Services Department staff, including team building and the development and implementation of retention strategies. Reviews performance measures and goals with staff regularly. Develops performance improvement plans as applicable for staff not meeting goals.
• Coordinates and oversees “Proxy Credentialing” functions and agreements associated with URMC’s contracted Telehealth services. Responsible for invoicing and monitoring accounts receivable for Credentials Verification Services provided to affiliates and non-affiliate clients in accordance with the contracts. Assists the Director and provides oversight of the fiscal management and administrative activities for the department. Responds to inquiries from other healthcare organizations and interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise. Represents the Medical Staff Services Department for various initiatives and/or committee meeting as needed. Serves as the primary back up to the MSS Department Director and other MSS Department Managers.Other duties as assigned.