Director Provider Credentialing

Description:

The Director of Provider Credentialing is responsible for coordinating the administrative function related to the credentialing and privileging process for all applicable medical staff and allied health professions. The Director is responsible for the entire physician credentialing & payor enrollment process which ensures everything is complete and up to date and meets all regulatory requirements. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statutes and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing database system and related applications. Develops departmental plans, budgets and directs staff as appropriate. This position maintains a high level of confidentiality, attention to detail, & professionalism.

ESSENTIAL FUNCTIONS:

To perform this job successfully, an individual must be able to perform each essential function satisfactorily with or without accommodation. The requirements listed below are representative, but not all inclusive, of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential job functions.

• Provides leadership, direction, process improvement models, and initiatives and establishes evidence-based, best practice analysis to improve/establish work standards
• Responsible for leading, coordinating, monitoring, and maintaining the accuracy and integrity of the credentialing and re-credentialing process in the California Market.
• Develop new processes and organization with the appropriate skillset to effectively and efficiently perform credentialing including provider credentialing, hospital privilege credentialing, and payer enrollment.
• Individual responsibility for credentialing decisions and authorizing clinician billable service.
• Experienced leadership required for multi-faced environment; role primarily focuses on tactical execution. Receives assignments in the form of objectives and determines how to use resources to meet schedules and goals.
• Provides oversight of the process by maintaining a working knowledge of requirements of Center of Medicaid/Medicare Services ("CMS"), National Committee for Quality Assurance (" NCQA") and 3rd party insurance requirements.
• Works with Field Management and the Acquisition Team to identify and start the credentialing process early with as much advance notice as possible, as to not negatively affect the Company’s billing process.
• Provide effective leadership, coaching, counseling, evaluating, and mentoring of staff in an effort to identify and implement opportunities for improvement.
• Participates in Human Resources related functions, such as Interviewing, Identifying, Selecting and Developing talent, Performance Appraisals (30, 60, 90 day, annual), Disciplinary Actions, Time Card Approvals, and Salary Administration.
• Responsible for developing, mentoring, and guiding team members for future growth and identify resource needs with appropriate approval
• Maintains an appropriate professional appearance and demeanor in accordance with Company policies.
• Keep commitments and keep direct supervisor informed of work progress, timetables, and issues.
• Maintain strict compliance with State, Federal and other regulations (e.g., OSHA, WC, HIPAA, ADA, FEHA, DOL, HR policies and practices).
• Other duties as assigned by management.

Requirements:

QUALIFICATION GUIDELINES: REQUIRED:

• At least 8-10 or more years of related work experience.
• Operational management knowledge of medical offices.
• Equivalent to high school diploma or general education degree (GED). Director, Provider Credentialing

DESIRABLE:

• Associates or Bachelor’s Degree.
• Knowledge of WORD, EXCEL, POWERPOINT and Care Cloud applications.
• Experience leading a team, mentoring and coaching subordinates.
• Experience with Credentialing of Healthcare Professionals; experience in the Ophthalmic industry.

CERTIFICATES/LICENSES/REGISTRATIONS:

• Certified Credentialing Specialist (preferred