Credentialing Manager

Job Summary:

As a Credentialing Manager, you will play a pivotal role in overseeing the credentialing process for healthcare providers, ensuring compliance with health plan guidelines, accreditation standards, and regulatory requirements. Your responsibilities will encompass managing the credentialing team, collaborating with various departments, and maintaining accurate databases. Additionally, you will actively engage with providers, resolving inquiries, and facilitating a positive experience throughout the credentialing lifecycle.

Duties and Responsibilities:

Credentialing Oversight:

• Initiate and manage the practitioner application process, overseeing document exchange, receipt, and analysis for Physicians, Physician Assistants, and Nurse Practitioners.
• Perform accurate and timely completion of credentialing applications, conducting thorough screenings for discrepancies and following up on outstanding information.
• Monitor provider licenses, certifications, and professional liability coverage to ensure currency.
• Oversee the maintenance of CAQH Proview and update data as provider information changes.
• Manage the timeline for credentialing, communicating effectively with leads and departments on status.
• Participate in Integration team activities for credentialing needs upon practice or provider acquisition.
• Prepare credentialing files for committee review; chair credentialing committee with board; present files for review per policy and record outcomes.

Compliance and Quality Assurance:

• Ensure adherence to Health Plan and IPA guidelines throughout the credentialing process.
• Conduct comprehensive quality assurance checks to maintain accuracy and completeness of provider files.
• Stay updated on industry changes related to credentialing and communicate these changes to the team.
• Maintain ongoing monitoring per policy requirements including OIG, SAM, State License Board etc.

Database Management:

• Oversee the expiration of licensure, board, and professional certifications for practitioners.
• Ensure precise data entry, safeguarding the integrity of credentialing information in relevant databases.
• Create, populate, maintain, and update the credentialing database to ensure data integrity.

Collaboration and Communication:

• Work closely with internal departments (Accounting, Contracting, etc.) to streamline the credentialing process.
• Actively participate in team meetings and process improvement initiatives.
• Maintain a positive, professional relationship with the provider network, addressing credentialing-related inquiries.
• Collaborate with revenue cycle department and clinic leads to resolve denials related to credentialing efficiently.

Provider Network Operations:

• Provide oversight for Provider Network Operations, including Provider Orientations, Education, and Conflict Resolution.
• Advise providers in maintaining compliance with health plan requirements.

Contracting Support:

• Support network development by researching, recruiting, and negotiating with providers.
• Assist in the contracting/re-contracting process, ensuring network adequacy and issue escalations.

Reporting and Documentation:

• Maintain tracking systems and publish reports according to departmental procedures.
• Participate in the evaluation of the provider network and contribute to the implementation of strategic plans.

Qualifications:

• Bachelor's degree in a related field; Master's degree preferred.
• Extensive experience in credentialing, contracting, and provider network operations.
• Strong knowledge of health plan guidelines, accreditation standards, and regulatory requirements.
• Strong knowledge of CMS Credentialing regulations
• Knowledge of HICE regulations and tools
• Excellent communication, negotiation, and interpersonal skills.
• Ability to manage and lead a team effectively.
• Experience with CAQH CVO preferred.
• Experience with Quick Cap 7 health care administrative software preferred.

Job Type: Full-time

Pay: $70, $95,000.00 per year

Benefits:

• Dental insurance
• Health insurance
• Paid time off
• Vision insurance

Ability to Relocate:

• Riverside, CA 92501: Relocate before starting work (Required)

Work Location: In person