Credentialing Manager

Advanced Health is a locally owned and operated Coordinated Care Organization (CCO) serving all Coos and Curry County communities.

We are searching for collaborative, innovative people committed to a shared community vision for health to join our team.

We are currently hiring a Credentialing Manager If you are proficient in credentialing management, a skilled problem solver and researcher, and value being part of a team that makes a difference, you may be the right person for the position Apply today We are committed to offering: Competitive wages Competitive benefits Paid Time Off (PTO) Sick leave Health and life insurance FSA and HSA 401(k) retirement with generous employer match Profit-sharing Team-oriented atmosphere that values each of our employees as an individual and their work-life balance Remote work options Flexible scheduling Every employee shares the responsibility for achieving the Quadruple Aim of health care reform: member engagement and satisfaction, improving quality of care, managing costs, and honoring diversity and equity.

By focusing on the people and communities we serve, we strive to ensure the dignity, privacy and confidentiality of members, their families, co-workers, and others.

All duties are performed in compliance with organization’s policies and procedure, contractual obligations, and within federal and state laws and guideline including HIPAA, OSHA, and Waste Fraud and Abuse regulations.

JOB PURPOSE: Healthcare Credentialing Manager This position is responsible for auditing, analyzing, modifying, and maintaining the company’s credentialing program and related systems for all Participating Providers and non-contracted Providers.

ESSENTIAL RESPONSIBILITIES: Healthcare Credentialing Manager Responsible for ensuring the efficient and timely completions of credentialing and re-credentialing activities for all Participating Providers and non-contracted providers, according to organization policy and procedure including primary source verification and evidence, screening and follow-up, data collection, data entry, document review, and reporting of all Participating Providers and facilities used to deliver covered services Maintain credentialing software database and individual provider files associated with credentialing activities Ensure that all credentialing files are current and complete pursuant to expiration date of medical licenses, board certification, professional liability insurance coverage, Drug Enforcement Agency (DEA), National Provider Identification (NPI) number, Department of Medical Assistance Programs (DMAP) number, and other pertinent information Track and report any credentialing irregularities or excluded individuals to OHA via administrative notice, systematic reporting requirements, or other appropriate means in a timely manner Manage and submit credentialing
– and network provider-related reporting to OHA, collecting key data sources, including but not limited to the quarterly provider capacity and annual narrative reports Maintain and report provider updates to Centene/Trillium under IPA contract with Trillium Perform credentialing audits of entities with contracted credentialing delegation.

(i.e.

CEP/VItuity) Lead coordinator for external credentialing audits conducted by State and Federal agencies and outside delegation contracts.

(HSAG, OHA, OIG, Trillium/Centene, etc.)Communicate with internal and external customers on a regular basis regarding credentialing of providers Ensure timely processing for each provider initial and re-credentialing application to mitigate financial impacts to the health care system Process credentialing and re-credentialing applications in credentialing software Work closely with internal business and external business partners to answer questions regarding credentialing / re-credentialing, provider data and the provider directory Implement and maintain annual education and training for employees and provide appropriate targeted training and tools to credentialing staff ensure adequate knowledge and understanding of the credentialing of providers and the delivery of covered services Ensure the capture and maintenance of complete and accurate provider data; perform regular audits on credentialing files and provider data Formulate strategic department, both short term and long term, plans based on analysis of current processes and implement department policies Monitor key indicators of department performance and take steps to ensure established targets are met Develop and maintain credentialing policies and procedures and provide input related to credentialing system and provider data management system Participate in corporate committees, work groups and task forces as needed to represent Credentialing department interests Ensure compliance with company policies and procedures as applicable to area(s) of responsibility Handle confidential information and materials appropriately and maintains a secure work area Other duties as assigned ESSENTIAL RESPONSIBILITIES: ORGANIZATIONAL TEAM MEMBER Participate in quality and organizational process improvement activities and teams when requested Support and contribute to effective safety, quality, and risk management efforts by adhering to established; policies and procedures, maintaining a safe environment, promoting accident prevention, and identifying and reporting potential liabilities Openly, clearly, and respectfully share and receive information, opinions, concerns, and feedback in a supportive manner Work collaboratively by mentoring new and existing co-workers, building bridges, and creating rapport with team members across the organization Provide excellent customer service to all internal and external customers, which includes team members, members, students, visitors, and vendors, by consistently exceeding the customer’s expectations Recognize new developments and remain current in credentialing best practice standards and anticipate organizational modifications Advance personal knowledge base by pursuing continuing education to enhance professional competence Promote individual and organizational integrity by conducting oneself in an ethical manner ESSENTIAL RESPONSIBILITIES: Personnel Management Plan, orient and assign work to personnel that supports goals and objectives contained in the organization’s Strategic Plan Structure and lead operational teams to deliver outstanding team-based services Oversee, direct, and organize the work of support and operational teams and personnel Promote a culture of risk-management, team-based, values-based, high-performance, and continually improving practice that values learning and a commitment to quality QUALIFICATION, EDUCATION, AND EXPERIENCE REQUIREMENTS Bachelor’s degree in healthcare, business, or related field required or equivalent combination of education, knowledge, and work experience Certified Provider Credentialing Specialist required Willing to consider applicant that is currently working to obtain [SH1] though must meet eligibility requirements for testing and certification must be obtained within one year of hire Minimum of three (3) years working in a role with significant credentialing and provider data management responsibility required, MD-Staff credentialing software strongly preferred Previous supervisory experience or significant experience as a Lead with responsibility for coordinating work, resolving issues, and providing content/process expertise required Previous experience with data base administration Health plan or managed care experience strongly preferred KNOWLEDGE, SKILLS, AND ABILITIES Knowledge of national credentialing standards, including NCQA Extensive working knowledge of governmental Medicare/Medicaid insurance rules and regulations Demonstrated skills in customer service, problem identification, problem solving, accuracy and attention to detail, data analysis, time management and managing priorities Strong knowledge of provider and contract configuration Basic knowledge of claims processing Strong critical thinking and problem-solving skills High level of accuracy and attention to detail Strong research skills Knowledge and understanding of how the positions’ responsibilities contribute to the department and company goals and mission Knowledge of federal and state laws including OSHA, HIPAA, Waste Fraud and Abuse Awareness and understanding of equity, equity lens, diversity, and inclusion Training in or awareness of Health Literacy, Poverty Informed, Systemic Oppression, language access and the use of healthcare interpreters, uses of data to drive health equity, Cultural Awareness, Trauma-Informed Care, Adverse Childhood Experiences (ACEs), Culturally and Linguistically Appropriate Service (CLAS) Standards, and universal access Proficient in Microsoft Office Suite Proficient in analytical or compliance software Non-judgmental attitude Ability to meet competing deadlines with successful outcomes Ability to work independently and be a self-starter Ability to use logic and reasoning to identify the strengths and weaknesses of alternative solutions, conclusions, or approaches to problems Ability to report to work as scheduled, and willingness to work a flexible schedule when needed Ability to handle stress and sensitive situations effectively while projecting a professional attitude Ability to communicate professionally, both orally and in writing Ability to work with diverse populations Ability to relate to and interact with people of differing personalities and backgrounds Sensitive to economic considerations, human needs and aware of how one’s actions may affect others Ability to organize and work in a sensitive manner with people from other cultures Poised; maintains composure and sense of purpose WORKING CONDITIONS This position must have the ability to remain in a stationary position, occasionally move about inside the office to access office machinery, printer, etc., frequently communicate and exchange accurate information.

Work Condition: Employee generally works within the interior of an office environment.

Employee may travel locally and be responsible for own transportation.

Out of area travel may be required on occasion.

Hours of operations and specific staff scheduling may vary between worksite based on operational need.

The general environment is clean with a comfortable temperature and moderate noise level.

Exposed to: Cold/heat controls, close contact with employees and the general public.

Machines, equipment, tools and supplies used: Constantly operates a computer or other office productivity machinery, such as postage machine, fax, copier, calculator, multi-line telephone system, scanner May answer a high volume of telephone calls, complete documentation, and use computer programs to either obtain or record information Multiple Duties: Must be able to work under conditions of frequent interruption and be able to stay on task.

This position is full-time, Monday through Friday, generally 8am to 5pm.

Remote and onsite applicants are being considered.