Credential Manager Jobs in Kentucky (NOW HIRING)

King of Prussia
950 Pulaski Dr
Suite100
King Of Prussia, PA 19406, USA

King of Prussia
950 Pulaski Dr
Suite100
King Of Prussia, PA 19406, USA

JOB TITLE: Credentialing Manager FLSA STATUS (Exempt/Non-Exempt): Exempt SUPERVISION RECEIVED: Reports toCEO SUPERVISION EXERCISED: Credentialing Department

GENERAL STATEMENT OF DUTIES

Responsible for managingthecredentialing department and overseeing the systems and processes associated with provider credentialing, recredentialing, licensing, privileging, payer enrollment, and provider onboarding. Ensures physicians and other healthcare providers are credentialed accurately andtimelyand that allrequired providercredentials, documentation, and information aremaintainedwithin the organization's credentialing systems. Partners with physicians/providers, Human Resources, Operations, Revenue Cycle Management, hospitals, health plans, and other internal and external stakeholders tofacilitateprovider onboarding, maintain ongoing credentialing compliance, and resolve credentialing-related issues.

ESSENTIAL FUNCTIONS

• Manages thetimelyandaccuratecompletion of physician and other healthcareprovidercredentialing and recredentialing applications.
• Manages and supervises credentialing staff, including hiring, training, workload management, performance reviews, coaching, development, and ongoing performance management.
• Participates in and supports the provider onboarding process to ensure credentialing activities areinitiatedand completed within requiredtimeframes.
• Overseesprimary source verification and collection of required provider documentation, including professional licenses, board certifications, professional liability insurance, DEA registrations, National Practitioner Data Bank (NPDB) reports, and other required credentials.
• Ensures credentialing and recredentialing activitiescomply withapplicable Joint Commission and NCQA standards, payer requirements, organizational policies, and other applicable credentialing requirements.
• Oversees provider enrollment and maintenance with Medicare, Medicaid, commercial health plans, and other applicable payers.
• Coordinates hospital and facility credentialing, privileging, and reappointment processes, as applicable.
• Ensuresaccuratecollection, tracking, and documentation of providerexpirableand renewal requirements within establishedtimeframes.
• Maintainsaccurateand current provider information within CAQH and other applicable credentialing, payer, and provider databases.
• Ensureshospitals, health plans, medical groups, and other applicable entities are appropriately notified of provider demographic and practice changes.
• Oversees the processing of provider terminations from payer networks, hospitals, facilities, and other applicable entities.
• Collects, reviews, andauditsdisciplinary reports, OIG exclusion information, NPDB reports, state licensing board information, and other applicable sanction ormonitoringreports and escalates concerns asappropriate.
• Provides consistent andtimelyfollow-up on outstanding credentialing and recredentialing files and escalates delays, deficiencies, or other concerns toappropriate leadershipwhen necessary.
• Establishes andmaintainseffective processes for credentialing file collection, document management, scanning, data capture, and data entry.
• Monitors the timeliness, completeness, and accuracy of credentialing documentation and provider data.
• Maintains current and archivedprovidercredentialing records and ensures files are complete,accurate, confidential, andaudit-ready.
• Prepares credentialing reports, adverse action documentation, provider status reports, and other credentialing reports as requested.
• Partners with Revenue Cycle Management and other departments to research and resolve claim denials or reimbursement issues related to provider credentialing or enrollment.
• Identifiestrends in credentialing-related denials, delays, and discrepancies and develops action plans and process improvements to address identified issues.
• Applies performance improvement principles to continually evaluate and improve credentialing department processes, workflows, accuracy, and efficiency.
• Establishes andmaintainseffective communication with physicians/providers, hospitals, facilities, health plans, credentialing agencies, and internal departments.
• Serves as a resource to physicians/providers and leadershipregardingcredentialing, recredentialing, licensing, enrollment, and privileging requirements and status.
• Maintains the privacy and confidentiality of allproviderprofessional and personal information obtained in the performance of job responsibilities.
• Performs other duties as assigned.

EDUCATION

• High school diploma or GEDrequired.
• Associate's orbachelor's degree in Healthcare Administration, Business Administration, or a related field preferred.
• Certified Professional Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) certification preferred.

EXPERIENCE

• Minimum of two (2) years of experience in healthcare credentialing, provider enrollment, medical staff services, or a relatedcredentialing functionrequired.
• Prior supervisory or leadership experience preferred.
• Experience with physician and other healthcareprovidercredentialing and recredentialing preferred.
• Experience with payer enrollment, CAQH, Medicare, Medicaid, and commercial health plans preferred.
• Experience working within a multi-site physician practice or outpatient healthcare organization preferred.

KNOWLEDGE

• Knowledge of provider credentialing and recredentialing processes and regulatory standards.
• Knowledge of payer enrollment requirements and healthcare payer processes.
• Knowledge of primary source verification requirements and credentialing documentation standards.
• Knowledge of credentialing timelines, providerexpirables, and renewal requirements.
• Knowledge of professional licensing, board certification, DEA registration, NPDB, OIG, and other applicableprovidercredentialing requirements.
• Knowledge of Joint Commission and NCQA credentialing standards, as applicable.
• Knowledge of CAQH and governmental and commercial payer enrollment processes.
• Knowledge of credentialing databases, computer systems, and Microsoft Office applications.
• Knowledge of changingpayerand credentialing requirements within the healthcare industry.

SKILLS

• Strong leadership and staff management skills.
• Excellent verbal and written communication skills.
• Skill inestablishingeffective working relationships with physicians/providers, leadership, staff, payers, hospitals, and other internal and external stakeholders.
• Skill in organizing and prioritizing daily work assignments.
• Skill in managing multiple credentialing processes and competing priorities simultaneously.
• Skill in meeting demanding and time-sensitive deadlines.
• Strong attention to detail and accuracy.
• Skill inidentifyingand resolving credentialing, enrollment, andproviderdata discrepancies.
• Skill in organization, problem-solving, and process improvement.
• Skill inmaintainingconfidentiality and handling sensitive provider information appropriately.

ABILITIES

• Ability to independently manage and oversee the credentialing function.
• Ability to supervise, train, coach, and develop credentialing staff.
• Ability toestablishand maintain effective working relationships with internal and external stakeholders.
• Ability to communicate effectively with physicians/providers, credentialing agencies, hospitals, health plans, leadership, and staff.
• Ability to organize and efficiently manage multiple credentialing activities and projects.
• Ability to exercise independent judgment and makeappropriate decisions.
• Ability toidentifypotential credentialing delays or compliance concerns and upscale them appropriately.
• Ability to manage sensitive and confidential information and exerciseappropriate discretion.
• Ability to meet established credentialing, recredentialing, enrollment, and renewal deadlines.

ENVIRONMENTAL WORKING CONDITIONS

• Normal office and outpatient healthcare environment.

PHYSICAL/MENTAL DEMANDS

• Requires sitting, standing, walking, and occasional bending and stretching associated with a normal office environment.
• Requires manual dexterity for computer, telephone, and other office equipmentuse.
• Requires sustained attention to detail and the ability to manage multiple priorities and time-sensitive deadlines.
• Requires the ability to communicate professionally and effectively with physicians/providers, leadership, staff, payers, hospitals, and external organizations.

ORGANIZATIONAL REQUIREMENTS

• HOPCo'sMission, Vision, and Values must be acknowledged and adhered to.
• Completes all required organizational training and education.
• Maintains compliance withallpolicies and procedures.

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Equal Opportunity Employer
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