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TriWest Healthcare Alliance · 2 days ago

Mgr, Prov Cert & Credentialing

United States

Full-time

Remote

Mid, Senior Level

$99K/yr - $110K/yr

3+ years exp

TriWest Healthcare Alliance is dedicated to serving America's heroes by connecting them to healthcare in the community. The Manager of Provider Certification & Credentialing will oversee provider certification and credentialing operations to ensure compliance with regulatory standards and lead communication with stakeholders.

Health Care

No H1B

Security Clearance Required

U.S. Citizen Only

Responsibilities

Manages the daily operations for and staff performing initial credentialing, re-credentialing, and delegated credentialing

Oversees the daily operations for and staff performing provider certifications

Coordinates the loading and maintenance of provider data (including adds, changes, and terms) for direct and corporate contracted providers. Ensures provider data is entered into the credentialing database according to established guidelines and procedures

Assists with the annual review and maintenance of certification and credentialing policies and procedures to ensure compliance with applicable federal requirements and accreditation standards

Manages the preparation and responses for all credentialing-related audits, including but not limited to, internal, monthly and annual regulatory, as well as accreditation audits

Serves as the point of contact for certification and/or credentialing-related questions from network subcontractors and representatives from federal agencies

Develops and administers the annual audit plan for all delegated entities, including network subcontractors, direct contracted providers, and corporate contracted providers

Routinely reviews department procedures and processes to identify opportunities for improvement, incorporating existing or new technologies, tools, and resources

Assists with reviewing and ensuring provider-facing documents/materials includes current and accurate certification and/or credentialing information

Manages the team’s workload to ensure established performance goals and production metrics are met on a daily/weekly/monthly basis. Ensures staff performance issues are addressed timely and performance improvement plans implemented as needed

Conducts annual performance reviews according to TriWest guidelines

Oversees staff training and development. Communicates new and/or changes to existing processes, regulations, and standards to staff in a timely manner

Ensures staff is fully informed through regular team meetings and individual staff concerns/issues are addressed through regular 1:1 meetings

Assists with identifying and justifying additional resource needs for the team to ensure performance goals are met as well as compliance with regulatory requirements and accreditation standards

Attends meetings outside of normal business hours as required

Regular and reliable attendance at work

Performs other duties as assigned

Qualification

Credentialing experienceProvider data managementAccreditation standards knowledgeRegulatory requirements knowledgeAnalytical skillsProcess improvement skillsCommunication skillsTeam-buildingCustomer serviceTechnical skillsLeadershipTime managementOrganizational skills

Required

Bachelor's degree in healthcare administration, business administration, or related field; or equivalent experience

3+ years of credentialing experience in a leadership role

3+ years of provider data management system experience

U.S. Citizen

Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation

Thorough knowledge of provider credentialing processes (initial, re-credentialing, delegated), provider certification processes, provider data management processes, accreditation standards for URAC and/or NCQA, and regulatory requirements for VA CCN and/or TRICARE

Experience with credentialing applications/provider data management systems