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Curative · 1 hour ago

Credentialing Manager

Austin, TX

Full-time

Hybrid

Senior Level

5+ years exp

Curative is building the future of health insurance with a first-of-its-kind employer-based plan designed to remove financial barriers and make care truly accessible. The Credentialing Manager oversees the credentialing process and assigned staff to ensure compliance with state regulatory requirements for credentialing and recredentialing of participating providers and will work with Curative’s tech team to develop and implement a proprietary credentialing platform.

Health CareHealth DiagnosticsHealth InsuranceMedicalMedical DevicePersonal Health

Responsibilities

Manage a small credentialing staff responsible for direct credentialing, both physician and facility and overseeing delegated credentialing entities

Work with current credentialing vendor on issues related to their software, and assist in the development and transition to our new, proprietary platform

Work with our Operations and Technology teams to assure that provider data is accurately transmitted into the directory and claim system. Some experience with provider data maintenance is preferred

Maintaining, Tracking, and Managing rosters for accuracy and completeness for final reporting that is needed for timely setup for claims payment, member assignment, and directory display

Conduct audits to reduce errors and improve processes and performance, maintaining current provider data to ensure the quality of the network

Coordinate delegation audits to ensure compliance with state, federal, and NCQA standards, including scheduling audits, accurately completing delegation audit tools, and reporting outcomes to management

Participate in team meetings alongside other team members to discuss credentialing issues, provide feedback to support with suggestions for the development and improvement of workflow, and discuss process improvement change

Perform medical credentialing file/element investigation and primary source verification of provider and facility initial and re-credentialing applications, utilizing established standards, state regulatory, and NCQA requirements

Ensure timely compilation of applicant and verification elements to prevent any adverse outcomes or delays in processing applications/files

As needed, prepares agendas and related material for all Credentialing Committee meetings, including transcribing, and maintaining minutes for such meetings, along with ensuring expeditious follow- through on action items and policy changes

Analyzing credentialing standards and developing criteria to ensure compliance; revising general aspects of the credentialing and privileging process as necessary; making recommendations for revisions in development, current operating environment standards and enhancements as appropriate to the current policies and procedures

Ongoing monthly monitoring to ensure the quality and safety of care to members. Also, monitors for sanctions and tracks complaints, adverse events, and quality issues against practitioners through monthly queries and reports

Work adhering to US regulatory and Quality System requirements (21 CFR 820, etc)

This position assumes and performs other duties as assigned

Qualification

Provider credentialing experienceNCQA credentialing standardsCredentialing software experienceProcess ImprovementSupervisory experienceBachelor’s DegreeManaged Care CredentialingTDI practicesProficient in Google SuiteProficient in Microsoft SuiteCommunication skillsLeadership skillsSelf-starter

Required

5+ years of provider credentialing experience, 1-year supervisory experience to include managing offshore resources

High degree of knowledge in NCQA and/or JCO credentialing standards

Proficient computer experience, i.e. Google Suite and Microsoft Suite of applications

Significant experience with credentialing software (Medallion, CAQH, CredSimple)

Experience with Process Improvement

Excellent written, verbal, presentation and leadership skills. Self-starter who can work independently with minimal supervision

Bachelor's Degree (BA) from four year college or university, or one to two years of related experience and/or training, or equivalent work experience with focus in credentialing