Credentialing Manager

POSITION SUMMARY
- The Credentialing Manager will be responsible for managing provider credentialing/re-credentialing, understanding the intricacies of payor credentialing while also having the ability to identify and resolve complex claims issues.  The ideal candidate will have experience in both credentialing and medical claims, with a strong understanding of healthcare regulations, payer requirements, and revenue cycle workflows. - The Credentialing Manger will work closely with the National Director of Credentialing to define departmental processes, execute strategic departmental initiatives, and have the ability to communicate high-level issues to Leadership when needed to ensure barriers do not hinder progress and implementation. - The Credentialing Manager will act as a liaison between internal departments, (operations/onboarding/Conifer/RCM, managed care) and health plan partners to and diagnose/resolve claim issues, educate, and work to ensure credentialing activity across the department was successful through claims payment. This position provides oversight of the Credentialing Worklists and metrics across Athena in addition to desperate platforms and manages the day-to-day relationships with all.   This position also ensures the team meets timelines and KPIs around Revenue Cycle and manages/retrains when performance metrics are not met. - The candidate will have the ability to define SOPs around credentialing/claims collaboration, structure definition, issue resolution and workflows. - The Credentialing Manager will have an in-depth understanding of Revenue Cycle, Managed Care, Credentialing and claims processing to perform root-cause analysis and quickly resolve issues that stagnate claims payment and payment access issues. - The Credentialing Manager will have the ability to effectively communicate to all levels internally and externally as well as produce and present productivity reports and discuss mitigation plans through to resolution. - The Manager will elevate health plan relationships to ensure issues are resolved quickly.  This requires the individual to represent TPR physicians with all of National Leaders for our top payors within each market as well as nationally to include Aetna, Humana, United, Cigna, Blue Cross/Blue Shield, and Aetna as well as other regional and local plans. - The manager will have direct reports.

• Provide oversight and management of the credentialing worklists in Athena to resolve RCM issues impacted by credentialing are being prioritized, worked through to resolution and resolved prior to the claim is rendered “dead” by the Health Plan.
• Elevating relationships to drive claims projects to successfully closed/paid.
• Elevate Health Plan partner relationships to drive internal strategies around onboarding and acquisitions by representing TPR with accurate data input/submissions, challenging payor agendas, and timely project completion.
• Prioritize root cause analysis and problem-solving daily to ensure claims payment is successful and patient access is never hindered due to administrative challenges.
• Lead all training needs for the team within the manager's scope – initial training as well as retraining to ensure the right tools and knowledge are provided to the team to continually drive success and excellence through a consistently changing environment.

Knowledge, Skills, Abilities

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The list below are representative of the knowledge, skill and/or ability. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Required:

• Excellent analytical abilities and communication skills including the ability to communicate with stakeholders and decision-makers across the spectrum of the organization, from senior business leaders to subordinates
• Experience in progressive health care management with emphasis in health plan/provider contracting and physician group management/contracting
• In Depth knowledge of health plan and governmental payer credentialing, enrollment, medical claims payment and requirements.
• Ability to work within a deadline-intense environment.
• Demonstrated problem-solving and customer service skills.
• Knowledge of primary source verification, provider enrollment, and NCQA credentialing requirements.
• Proficient working knowledge of Echo or other credentialing systems, Athena and MS Office Suite of products including but not limited to Word, Excel, Project, and PowerPoint.

Preferred:

• Experience with multi-specialty or large group practices across multiple states/Tax IDs
• Bachelor’s degree in healthcare management, public health, accounting, finance, business, social or behavioral sciences preferred or equivalent experience
• 7-10 years of previous managed care experience and 5+ years’ experience in a credentialing leadership role

Education/Experience

Required:

• Bachelor’s degree in healthcare management, public health, accounting, finance, business, social or behavioral sciences preferred or equivalent experience
• 7-10 years of previous managed care experience and 5+ years’ experience in a credentialing leadership role