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Spectrum Health Services, Inc. · 3 weeks ago

Credentialing Manager

Philadelphia, PA

Full-time

Onsite

Senior Level

6+ years exp

Spectrum Health Services, Inc. is a healthcare organization seeking a Credentialing Manager to oversee practitioner applications and ensure eligibility. The role involves conducting background investigations, preparing credentials files for medical staff committees, and maintaining provider certification databases.

DentalHealth CareMedicalNon ProfitPharmaceuticalPsychology

Responsibilities

Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility

Conducts thorough background investigation, research, and primary source verification of all components of the application file

Identifies issues that require additional investigation and evaluation, validates discrepancies, and ensures appropriate follow up

Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion within time periods specified

Successfully completing and maintaining initial and subsequent individual provider payor enrollments, i.e., Medicaid, Medicare, Commercial payors, CHIP, & other third-party insurance carriers

Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions

Maintains physical and electronic data base of provider certifications, documents, expiration dates, and payor enrollment information

Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise

Assists with managed care delegated credentialing audits; conducts internal file audits

Monitors the initial, reappointment and expirable process for all SHS Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (HRSA, CMS, federal and state), as well as Rules and Regulations, policies and procedures, and delegated contracts

Performs miscellaneous job-related duties as assigned

Maintains a proactive working knowledge of all clinical service lines relative to the credentialing process

Establishes goals and develops training processes to ensure maximization of technical support available

Analyzes credentialing reporting using the Med-Trainer platform and internally maintained spreadsheets

Collaborates with Revenue Cycle Director and Revenue Cycle Manager to maintain to all payor rosters

Work in partnership with Human Resources Department to optimize provider documentation collection

Establishes quality review processes to ensure the effectiveness of the credentialing process and make modifications as needed

Ensures areas of responsibility achieve quarterly and annual goals and other established KPI’s

Complies with federal and state laws, SHS policies and procedures related to revenue cycle management

This position does not supervise others

Qualification

Medical credentialingPrivileging proceduresDatabase managementAccreditation knowledgeHealthcare operations knowledgeAnalytical skillsJudgment skillsEffective communication

Required

High school diploma or GED; at least 6 years of experience with 4 years directly related to health center medical staff or managed care credentialing

Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis

Ability to communicate effectively, both orally and in writing

Knowledge of related accreditation and certification requirements

Knowledge of medical credentialing and privileging procedures and standards

Ability to analyze, interpret and draw inferences from research findings, and prepare reports

Working knowledge of clinical and/or hospital operations and procedures

Ability to use independent judgment to manage and impart confidential information

Database management skills including querying, reporting, and document generation

Ability to make administrative/procedural decisions and judgments