Credentialing Director

Summary of Position

• Develop and implement provider credentialing related policies, procedures, goals, and budget.
• Ensure that the department complies with provider credentialing related DOH (Department of Health), CMS (Centers for Medicare and Medicaid Services), and NCQA (National Committee for Quality Assurance) guidelines.
• Negotiate delegated agreements with health plans. Develop, implement and manage solutions for physician relation issues and related billing with managed care organizations.
• Act as liaison between Executive leadership, Medical Directors, and health plans to solution/resolve issues.

Principal Accountabilities

Provider Credentialing and Enrollment Services

• Establish and maintain written credentialing related policies and procedures, ensuring compliance with federal, state, health plan, and NCQA regulations and guidelines.
• Direct the credentialing and re-credentialing application process for AdvantageCare Physicians (ACPNY) and AdvantageCare Bronx. Evaluate the credentials of all new providers joining ACPNY and AdvantageCare Bronx; audit files prepared by the credentialing specialists.
• Prepare documents for review and present to ACPNY senior leadership at monthly credentialing meetings.
• Manage the enrollment and revalidation of ACPNY and AdvantageCare Bronx providers in Medicare and Medicaid programs.
• Ensure that group enrollment certifications are updated/current.
• Direct day-to-day operations of the credentialing function.
• Maintain appropriate staffing and productivity to meet targeted service levels, turnaround times, and satisfaction/quality levels.
• Audit staff work to ensure that documentation is appropriate and stored in accordance with security and confidentiality protocols. Ensure initial & re-credentialing application files are maintained.
• Review and evaluate all credentialing delegation contracts.
• Manage all annual delegated credentialing audits; respond to audit requests.
• Review monthly compliance reports to ensure providers are in good standing with all regulatory agencies.
• Manage/monitor primary care physician member panel assignments including the submission of panel changes to health plans as necessary; ensuring the departure and arrival dates of credentialed providers are tracked.
• Provide verification requests for providers who have left ACPNY.
• Manage the credentialing vendor contract.
• Oversee the enrollment of providers with delegated health plans; Review weekly provider enrollment and evaluate vendor performance.
• Design and direct the use of the data fields in the credentialing database to ensure that appropriate information is captured to enable accurate reporting. Develop provider reports for internal and external partners upon request.

Provider Credentialing and Enrollment Data and Integrity Services

• Provide leadership and direction to maintain the integrity of the provider database for accurate display of information and credentialed provider reports. Ensure preparation of monthly provider participation reports.
• Communicate with medical office staff on provider enrollment status.
• Collaborate with marketing department to ensure accuracy of ACPNY website provider information.
• Ensure collaboration with EPIC interface team and credentialing vendor to maintain accuracy of the daily import file into EPIC. Analyze provider database; update as appropriate.

Payor Oversight / Support / Liaison Services

• Cultivate, maintain, and enhance ACPNY and health plan relationships. Serve as liaison between health plans, providers, and medical offices. Establish provider relations contacts with health plans.
• Conduct regular meetings with high-volume health plans to review and resolve provider file and claim issues including but not limited to Credentialing issues, Contractual Payment issues, and other Revenue Cycle billing issues as needed.
• Identify and track revenue cycle related issues impacting health plan payments for ACPNY and AdvantageCare Bronx. Escalate issues with payors and collaborate with provider representatives to resolve both claim and provider file issues.

Contract Support Services

• Review and direct the implementation of new managed care contracts in conjunction with revenue cycle, legal and strategy team. Maintain current knowledge of health plan contract reimbursement arrangements.
• Analyze health plan group contract fee schedule. Make recommendations to contracting team as appropriate.
• Manage contract implementation with Contract Management vendor ensuring all contractual terms in relation to payments are loaded to validate all incoming payments for accuracy.
• Leverage the contract management tool to identify claims that are incorrectly paid.
• Provide health plan contracts and fee schedules to the vendor so that claims payments can be evaluated.
• Establish thresholds for claim escalation and follow up with health plans to recover underpayments.
• Meet monthly with vendor and claims processors to review process and adjust priorities as appropriate to maximize return on investment.

Other Duties:

• Complete other special projects and job-related duties as designated by Senior Management.

Education, Training, Licenses, Certifications

• Bachelor’s degree
• Master’s degree preferred (Health or Business Administration)

Relevant Work Experience, Knowledge, Skills, and Abilities

• 10 + years’ progressive related experience working with managed care organizations, inclusive of management experience.
• Additional experience/specialized training may be considered in lieu of educational requirement.
• Strong understanding of provider credentialing, related health plan processes and DOH, CMS and NCQA guidelines.
• Proficient with MS Office (Word, Excel, PowerPoint, Outlook, Teams, SharePoint, etc.) and credentialing software.
• Strong communication skills (verbal, written, presentation, interpersonal) with all types/levels of audiences.
• Strategic and tactical perspective on how to significantly improve operational performance.
• Ability to manage vendor line management and their respective staffs on a day-to-day basis.
• Experience using metrics to determine results; ability to implement and enforce SLAs (Service Level Agreements).
• Knowledge of contracts/terminology to determine alignment of results to goals.
• Experience with outsourced processes and vendor management.

Additional Information

• Requisition ID: 1000002036
• Hiring Range: $105,000-$195,000