Manager, Provider Credentialing & Enrollment

PURPOSE OF POSITION:

The Manager, Provider Credentialing & Enrollment includes ensuring all healthcare providers are appropriately credentialed and enrolled with payer, directly impacting clinical coverage, regulatory compliance, and reimbursement. The Manager leads the development, implementation and maintenance of the standardized practitioner credentialing department ensuring that all payer credentialing requirements are met in compliance with credentialing, regulatory and accreditation requirements ensuring timely reimbursement from third party payers for services provided. Promoting physician satisfaction by contributing to smooth onboarding processes in close collaboration with hospital Medical Staff Offices, operational teams, and Revenue Cycle staff.

PRIMARY DUTIES AND RESPONSIBILITIES:

1. Lead and develop ongoing strategic initiatives and planning with regards to the credentialing of all CCHC providers. Responsible for the identification of necessary upgrades to the provider enrollment system and oversight of such upgrades.
2. Develop, communicate, and maintain standard operating procedures for the Credentialing office. Direct and monitor processes related to accurate and timely functions of the Credentialing office.
3. Recruit, develop and retain high-performing credentialing and enrollment staff through training, performance management, workload balancing and succession planning.
4. Develop process improvement initiatives related to the Credentialing staff workflows.
5. Collaborate closely with the Medical Staff office of each hospital to ensure effective coordination between the hospital medical staff privileging process and third-party payer enrollment.
6. Maintain CCHC’s definitive, accurate and up-to-date “source of truth” for all providers generating revenue across all CCHC service lines.
7. Ensure established escalation pathways are utilized appropriately and timely to address delays or issues with provider credentialing and enrollment coordinating with revenue cycle, medical staff office, physician recruitment, payer representatives and leadership to facilitate timely resolution and enrollment with the appropriate CCHC entities, TINs as applicable, and following established policies and procedures.
8. Develop and maintain strong relationships with key stakeholders related to credentialing and reimbursement functions, including the Medical Staff Offices, the PHO, and Revenue Cycle senior leadership.
9. Ensure continuous readiness for regulatory, accreditation, and payer audits related to credentialing and enrollment, including preparation of documentation, response to findings, and implementation of corrective action plans.
10. Design and implement programs to build and foster positive relationships between providers, practice managers and managed care organizations.
11. Manage hospital and ancillary site re-credentialing activities.
12. Participate in working groups in support of system initiatives where provider data is required.
13. Audit output of the Credentialing and Enrollment team and the PHO enrollment database to ensure alignment with KPIs such as: average days to initial payer enrollment, new provider enrollment timeliness rates, recredentialing completion rate, delayed/lost revenue due to enrollment issues, credentialing file accuracy rate, enrollments completed per FTE
14. Audit payer enrollment files against the PHO enrollment database to identify and resolve issues and omissions.
15. Develop an effective reporting infrastructure with regular monitoring and analysis of quality and production outcomes for credentialing staff and implement corrective action plans, as necessary. Lead standardizing, creating, and sustaining a common culture of high performing operations.
16. Consistently provides service excellence to all patients, family members, visitors, volunteers and co-workers.
17. Challenges current working practices; identifies process improvement opportunities and presents recommendations and solutions to management. Engages and commits to the organization’s culture of continuous improvement by actively participating, supporting, and promoting CCHC Pillars of Excellence.

EDUCATION/EXPERIENCE/TRAINING :

• Bachelor’s degree preferred.
• Minimum 5 – 7 years progressively responsible management experience working in a Healthcare System.
• Experience utilizing automated systems and Microsoft Office including Word, PowerPoint, and Excel.
• Superior organizational and project management skills
• Proven ability to manage complex projects and to collaborate and work well with others; must be self-motivated, flexible, and able to manage several priorities at one time.
• Exceptional written and verbal communication skills
• Ability to build relationships with physicians, physician groups, other healthcare professionals and hospital partners is required.
• Demonstrated ability to translate strategic goals and objectives into practical operational plans.
• Understanding of managed care operations and principles and physician practice operations.
• Superior leadership, problem solving, team-building, and decision-making skills.
• Ability to work with minimal supervision.
• Requisite poise, judgment, and trustworthiness to represent the PHO to internal and external groups.
• Maintain information in a confidential manner according to policies.