Manager, Credentialing & Medical Staff

The successful candidate will be able to:

• Responsible for functions of the Medical Staff Office Coordinators in their absence as needed.
• Responsible for coordination and preparation of medical staff functions; prepares for committee meetings, takes minutes, processes, and distributes appropriate correspondence as needed in the absence of MSO Coordinators.
• Assists in compliance with the accrediting and regulatory agencies (i.e., Joint Commission, CMS, NJBOME, etc.) in regard to medical staff while developing and maintaining a working knowledge of the statutes and laws.
• Maintains the confidentiality of all business/work and medical staff information.
• Assists in managing the flow of information between the MSO team, Credentials and MEC Committee members, Medical Staff Leadership (including the Service, Department and Section Chairpersons) and the Chief Medical Officer, as needed.
• Maintains open communication with the Medical Staff, Administration, Hospital Departments, practitioner’s office staff, Corporate Office, and related health agencies. Identifies and works to solve problems as they arise.
• Maintains knowledge of standards of The Joint Commission, CMS, and State and Federal regulations related to Medical Staff organization.
• Maintains working knowledge of the Medical Staff Bylaws, Rules and Regulations, and Hospital policies, and works to ensure the medical staff’s compliance with the stated parameters.
• Attends Medical Staff meetings as necessary. Assists as needed with agenda and materials preparation. Records minutes at specified committees.
• Assumes responsibility and accountability as Custodian of Records for all files, minutes, reports, etc., relative to the activity of the Medical Staff.
• Composes and distributes monthly Medical Staff Calendar to the Corporate Credentialing and Medical Staff Affairs Department.
• Coordinates new physician orientation as directed by the Corporate Office.
• Schedules applicant interviews as directed by the Corporate Office.
• Maintains the electronic board with current information as directed by medical staff officers, and the Corporate Office
• Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility.
• Conducts thorough background investigation, research and primary source verification of all components of the application file.
• Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.
• Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within time periods specified.
• Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.
• Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.
• Assists with managed care delegated credentialing audits; conducts internal file audits.
• Utilizes the Cactus credentialing database, optimizing efficiency, and performs query, report, and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.
• Monitors the initial, reappointment and expirable process for all medical staff, Allied Health Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.
• Develop and trains staff on regulations, policies, and procedures.
• Responsible for the regular review of internal processes in order to evaluate quality and efficiency within the Managed Care Department; recommend, administer and implement multiple activities in support of the Managed Care Department initiatives.
• Work with Managed Care Leadership to find efficiencies that will improve processes and communication.
• As a working supervisor, research and respond to routine, non-routine, complex and escalated inquiries in a timely and professional manner.
• Work with various departments to prevent issues as well as resolve elevated billing, reimbursement, health plan participation and credentialing issues.
• Maintain awareness of Payor Managed Care activities for changes in policies, authorization requirements and other processes that impact the Practice.
• Maintain the Payor matrix, including limited network participation, to ensure information is accurate and up to date.
• Maintain standard operating processes and procedures for contract monitoring and renewals.
• Gather current data and monitors changes on plan membership, patient volume, plan/benefit structure, reimbursement and other information needed to complete the contract profile.
• Review fee schedules for accuracy and identifies significant changes in reimbursement.
• Oversee activities responsible for ensuring that all Providers are credentialed with Payors and Hospitals in a timely and accurate fashion.
• Promptly communicate credentialing status to applicable parties.
• Monitor Payor directories to ensure all providers are listed accurately by plan
• Monitor trends to avoid minor issues from having a major impact on reimbursement and collections.
• Other duties as assigned.

What We're Looking For

• Five or more years in healthcare managed care contracting and medical staff experience
• Associates degree or BA needed
• Working knowledge of both Managed Care and Provider Insurance Credentialing
• Working knowledge of government and non-government insurance, payer requirements, and healthcare operations
• Excellent knowledge of healthcare revenue cycle, healthcare finance, CMS and state regulations and healthcare compliance requirements/activities
• Previous experience in a Medical Staff Services Administrative/Credentialing position required.
• Previous experience as a Medical Staff Coordinator or two or more years of experience in Medical Staff setting preferred
• Must have excellent organizational, time management, customer service and oral & verbal communications skills
• Ability to focus on detail while responding to multiple tasks simultaneously and work effectively in a goal-oriented team environment
• Must be able to maintain confidentiality of proprietary information related to all aspects of the position, hospital, medical staff, and allied health professional staff
• Excellent interpersonal skills, including the ability to communicate clearly, professionally, both verbally and in writing with a broad range of professionals and people of varying education and backgrounds.
• Proficiency in Cactus is critical.
• Proficiency in data entry, typing and computer skills using a variety of software programs including Microsoft Word, Excel, Access, Outlook, PowerPoint, and Cactus.
• Willingness to maintain a flexible work schedule as needed.
• Ability to adapt to changing schedules, deadlines and demands, and a heavy workload.

What We Offer

• Competitive compensation based on experience and qualifications: When determining the compensation, several factors may be considered including, years of relevant experience, credentials, union contracts, education, and internal equity.
• Comprehensive health, dental, and vision insurance
• 401K, Retirement savings plan with employer contribution
• Generous Paid Time Off (PTO) and paid holidays
• Tuition Reimbursement
• Opportunities for professional growth, development, and continuing education
• Employee wellness programs and resources

Influenza Vaccinations are a requirement for employment. If you are not currently vaccinated you will be required to receive the vaccination prior to hire date, during the influenza season, if you are offered employment, unless you request and receive an approved medical exemption.

We are an Equal Opportunity Employer encouraging diversity in the workplace. All qualified applicants will receive consideration for employment without regard to race, color, national origin, gender, age, religion, disability, sexual orientation, veteran status, marital status, or any other characteristic protected by law.