Be an early applicantLess than 25 applicants

Company

Clearlink Partners · 9 hours ago

Manager, Provider Credentialing & Data Management

United States

Full-time

Remote

Mid, Senior Level

$100K/yr - $150K/yr

5+ years exp

Maximize your interview chances

Health Care

Insider Connection @Clearlink Partners

Discover valuable connections within the company who might provide insights and potential referrals.
Get 3x more responses when you reach out via email instead of LinkedIn.

Responsibilities

Oversees the daily operations of the credentialing department functions

Oversees and has final approval of staffing for the department

Manages departmental leadership staff

Establish, implement, and monitor performance goals, metrics, and processes for the credentialing department

Initiate, develop, implement, optimize, and oversee provider data processes for the successful processing and verification of information during the applicant provider credentialling and recredentialing process

Ensure overall data quality, accuracy, completeness, and compliance with regulatory requirements and service level agreements

Prepare and maintain various reports, data, and summaries of credentialing activities.

Oversight of the preparation of applicant provider files and delegated entity provider roster Reports for review and approval during the credentialing and recredentialing cycle via the plan’s credentialing committee structure

Manage and present applicant files, delegated entity oversight reports and all other credentialing related defined reports to the credentialing committee and quality committee structures

Drive development and implementation of provider data interfaces, solutions, and auditable monitoring processes that include control and balance, exception handling, tracking, trending, and reporting

Work cross-functionally with product, health plan operations, medical affairs, and compliance teams to pull and analyze reports, ensuring that credentialing data aligns with organizational goals and regulatory standards

Responsible for proactive analysis of operational, service, and performance metrics and proactive initiation of performance improvement activities across the credentialing organization to achieve applicant provider credentialing files and provider data accuracy goals and service level agreements are met

Develop and maintain departmental policies, procedures and controls governing the credentialing process and the recording of provider data ensuring all policies and procedures and controls are in place, current, consistent across department and compliant with all legal, federal, state and accrediting standards

Work collaboratively with stakeholders and auditors to support internal and external audits

Maintains up-to-date knowledge of regulations and policies related to provider enrollment and credentialing at the Federal, State and Accreditation levels and acts as the Subject Matter Expert (SME) for credentialing processes and systems, providing guidance and support to staff and internal stakeholders to ensure compliance and efficiency

Oversight of the pre-delegation and ongoing delegation oversight processes related to contracted Delegated Provider entities. Ensures compliance with Model Audit Rules, State, Federal and Accrediting Agencies for all elements related to provider credentialing and data entry into claims system

Ensure quality related to credentialing operations and provider data by providing supporting departmental compliance oversight to support the continued growth and development of the organization

Leads active performance improvement initiatives to continually improve the level of productivity, performance, quality and compliance

Performs continuous review of business workflows to improve productivity and ensure provider satisfaction

Assures the confidentiality of provider information and ensure all provider information (electronic and hard copy) is secured

Ensure ongoing management of provider data by overseeing and/or conducting regular audits to ensure the accuracy and integrity of provider information in credentialing databases and systems, collaborating data management teams to develop and implement data quality initiatives, automate data entry processes, and resolve data discrepancies efficiently

Works closely with other business unit management to prepare and execute Provider data management plans and manage projects from beginning to end

Works with Plan business units and the IT department to ensure integrity and proper integration of all sources of enterprise provider data

Works in collaboration with senior management to develop appropriate departmental budgets and manage the budget monthly

Provide direction for health plan market/ product level operational oversight, management and performance improvement

Leverage industry expertise and expert knowledge, grounded in research and industry best practice, to provide high value consulting and advisory services

Deliver innovative, integrated solutions in support of client goals and engagements.

Provide delivery assurance support for engagements with assigned clients

Support or lead engagements ensuring completion of contracted services

Create and/ or manage to project plans

Write proposals/reports

Present to Client executives

Facilitate, advise and persuade key decision makers and influencers

Act in interim leadership capacity to provide supervision and oversight for teams and activities in a direct supervisory model

Identify opportunities to improve workflow, generate accurate, high-quality productivity, support organizational compliance with requirements and deliver reductions in associated costs with improvement in organizational quality performance in collaboration with Client leaders

Deliver concise, clear interpersonal communication to both internal and external audiences

Facilitate streamlined exchange of information with all levels of Clearlink and client organization(s)

Articulate performance across multiple projects with qualitative and quantitative results/ outcomes

Influence others to understand and accept strategies, goals and plans in response to changing business conditions

Develop methodologies and best practices to be applied across individual account strategies/ client plans

Establish goals and track progress to ensure achievement

Act in interim leadership capacity to provide supervision and oversight for teams and activities in a direct supervisory model

Identify opportunities to streamline and/ or automate workflows for accurate, high-quality production and improved results in cost savings, or outcomes measurement.

Coach and motivate staff to reach established engagement goals, deliverables and KPIs

Adapt processes, approach, plan and/ or activities in real time when targets, goals or timelines are at risk to ensure critical path activities are achieved

Support account management relationships with key client decision makers

Develop and deploy management reporting, if indicated, to support monitoring and improvement of performance, implementing plans for improvement as necessary

Responsible for the engagement quality, maintaining appropriate resources, competency training and education of staff

Responsible for approving and managing day to day engagement resourcing/ time and attendance as an Engagement Manager

Oversee compliance with internal client related audits, support Client preparation for external audits and surveys

Qualification

Find out how your skills align with this job's requirements. If anything seems off, you can easily click on the tags to select or unselect skills to reflect your actual expertise.

Credentialing managementManaged care knowledgeRegulatory complianceProject managementData managementPolicy developmentPerformance improvementComputer skillsHIPAA knowledgeNCQA knowledgeURAC knowledgeCollaboration skills

Required

Proficiency managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on time, in scope project and/ or strategic delivery.

Experience managing complex work in challenging environments through the alignment of resources and prioritization of efforts to ensure on time, in scope project and/ or strategic delivery.

Managed care industry knowledge in operations, costs, requirements, performance and outcomes

Product/ market operational experience in Commercial, Medicare, Medicare Advantage, Medicaid or associated lines of business

New program design and implementation to support needs/ requirements while ensuring stable operations and target outcomes

Strong understanding of legal and regulatory frameworks, healthcare administration models, and internal audit procedures.

Work closely with concepts such as HIPAA, as well as State’s Department of Insurance, Federal and State Health and Human Services, CMS, NCQA, and URAC, to ensure compliance with complex regulatory structures.

Strategic thinker with ability to produce and manage system-wide change through influence and persuasion

Knowledge of project management principles, methods, and techniques

Ability to meet strict deadlines

Attention to detail

Good communication skills

Knowledgeable in policies, laws and procedures

Strong computer skills

Proficiency in database management and data interfaces

Willingness to work as a team player

Good organizational skills

Must have a high school diploma or GED equivalent and computer experience

5 years credentialing specialist/coordinator experience in a managed care health plan setting or Credentialing Verification Organization (CVO). Demonstrated experience in developing policy and procedure documentation

Demonstrate knowledge of NCQA and/or URAC Accreditation requirements and demonstrated experience preparing for and leading accreditation and regulatory site surveys (NCQA, TJC, CMS, etc.)

Knowledge of medical credentialing and privileging procedures and standards

Must be able to sit in a chair for extended periods of time

Must be able to speak so that you are able to accurately express ideas by means of the spoken word

Must be able to hear, understand, and/or distinguish speech and/or other sounds in person, via telephone/cellular phone, and/or electronic devices

Must have ample dexterity which allows entering of text and/or data into a computer or other electronic device by means of a keyboard and/or mouse

Must be able to clearly use sight so that you are able to detect, determine, perceive, identify, recognize, judge, observe, inspect, estimate, and/or assess data or other information types

Must be able to fluently communicate both verbally and in writing using the English language