Credentialing Manager

PRIMARY ROLE OBJECTIVE:     

The Credentialing Manager is responsible for the process of credentialing and recredentialing for all Licensed Independent Practitioners (LIP’s) and Other Licensed or Certified Practitioners (OLCP’s).  This position ensures the Credentialing department fulfills its dual purpose of quality control and customer service and follows a comprehensive credentialing policy in partnership with our vendor.  The position requires independent work to build and implement the credentialing and provider enrollment protocol in accordance with JCAHO and HRSA.

 MAIN DUTIES AND RESPONSIBILITIES 

1.  Accurately manage all credentialing, privileging, insurance enrollment, re-credentialing, and facility credentialing for FHC.

2. Initiate and maintain provider relationships to support the credentialing and privileging

 Reviews applications, prepares verification letters, runs required reports and maintains internal database in conjunction with the credentialing software used.

1. Maintains the Credentialing and Privileging software, ensuring all information is updated.
2. Facilitates training of the HR team on the Credentialing and Privileging software.
3. Responsible gathering, verifying and evaluating highly confidential and sensitive health care practitioner credentials consistent with departmental guidelines and accreditation standards.
4. Efficiently perform all aspects of credentialing verification, including initial credentialing and recredentialing to ensure current credentials and timely handoff and/or review and approval of practitioner files.
5. Responsible for verifying and maintaining licensure for all LIP’s and OLCP’s.
6. Respond to all practitioner inquiries in a timely manner.
7. Monitor expiring licensure, DEA’s, board and professional certifications and other expire-able documents with practitioners within the prescribed timeframe.
8. Update electronic data files (for example:  FHC Providers; utilizing One Health Port and CAQH to submit practitioner data as required to credential individual practitioners).
9. Responsible for accurate data entry to ensure the integrity of credentialing information in applicable database(s).
10. Collaborate with Providers, clinic manager and/or external agencies to facilitate and ensure smooth hand-off during the credentialing process.
11. Use critical thinking skills to conduct follow-up with individual practitioners and internal and external entities to resolve discrepancies identified during the credentialing process.
12. Conduct sanctions and compliance monitoring and alert Director of any undisclosed negative findings immediately.
13. Actively participate in team meetings and process improvement initiatives to continuously improve work product quality and efficiency in collaboration with all stakeholders.
14. Shared responsibility for reviewing, processing and distributing incoming correspondences (i.e., interdepartmental mail, fax and email).
15. Participate and represent FHC in all Credentialing and Privileging audit activities (TJC and HRSA).
16. Prepare all Credentialing and Privileging audit items for FTCA deeming
17. Keep Director informed of potential credentialing or enrollment issues.
18. Conduct the initial credentialing and recredentialing packets for the Clinical Committee to review and approve in preparation for the Board of Directors (BOD).
19. Prepare letters of approval to be signed by CEO after BOD approval and send to providers and clinic managers with a copy of privileges.
20. Monitor the process for Facility Credentialing for DSHS and Medicare.
21. Monitor the process of Re-Validation of Facility NPI’s.
22. Provide Grant Related Credentialing Data
23. Complex/Advanced Privileging Training Verification (supplemental privilege requests).

Payer Enrollment Duties

1. Maintains knowledge of current health plan and agency requirements for credentialing providers.
2. Ensures practice addresses are current with health plans, agencies and other entities.
3. Audits health plan directories for current and accurate provider information.
4. Coordinates the enrollment and registration process for new payer enrollments as well as updates for providers already enrolled with the payers.
5. Completes all applications (online or paper) for the government payers (Medicare, Medicaid, Tricare), and all delegated and non-delegated commercial payers.
6. Tracks and maintains individual provider specific information in a database for new and ongoing enrollments and provides updates regarding changes for the enrolled providers for the commercial delegated payers (i.e. change in locations, addresses, phone numbers, tax ID’s, etc.)
7. Completes applications to revalidate Family Health Centers. individual location Domains and NPI’s as well as all providers with Medicare and Medicaid.
8. Coordinate signatures from the providers, Authorized and Delegated Officials for the Medicare applications and from Family Health Centers CEO for Medicaid, Medicare or insurance group changes.
9. Serves as a liaison for the Medical Staff and insurance vendor regarding credentialing.
10. Collaborates directly with providers and various department representatives (including billing) to obtain information related to practice addresses, taxonomy codes, and to secure provider and authorized official signatures.
11. Communicates the status of the applicant files directly to providers and various department representatives (including billing) and coordinates efforts to obtain necessary information and/or documentation to assure deadlines are met.
12. Notifies providers and various department representatives when confirmation is received from the payers that a provider has been approved and enrolled.
13. In conjunction with vendor documents and Tracks the Status of Provider Enrollment Applications.
14. Enters information onto and maintains the accuracy of an internal tracking spreadsheet such as:
    1. Ensures only the proper Providers are enrolled in their delegated plans
    2. Tracks the dates that payer applications have been sent to the payers
    3. Regularly checks the status of the applications submitted to the payers