The Manager of Provider Data Management oversees the operational processes and staff management, by monitoring productivity through established standards and goals, creating and implementing efficient policies and procedures that meet the business needs, and ensuring compliance with all regulatory requirements.
GOALS AND ESSENTIAL FUNCTIONS
· Provide leadership that creates and maintains effective and efficient processes, policies and procedures for provider data management that meet standards set forth by, State and CMS regulations.
· Solve problems with an ability to creatively exercise initiative, logic and sound judgment in the development of strategies, business rules, policies and procedures.
· Assess and continuously improve efficient processes, file management, system set-up, reporting requirements.
· Make recommendations for improvement and maximize use of technology.
· Maintain a library of processes, policies and procedures.
· Work collaboratively with providers and internal personnel, in particular, quality management, contracting, provider relations and IT.
· Use and build effective communication skills and critical thinking to problem solve, communicate with staff, executives, peers and external business associates. Build consensus with peers and business associates.
· Manage quarterly State provider network submissions to ensure network adequacy requirements and minimal to no deficiencies.
· Manage all delegated credentialing relationships and perform necessary auditing and reporting functions according to delegation agreements, regulations and established standards.
· Process all monthly delegated credentialing rosters to ensure providers are loaded in the FACETS system.
· Develop and maintain a process for accurately and timely processing provider demographic changes.
· Maintain provider data integrity accuracy through auditing and reporting tools.
· Set example as leader. Mentor and coach staff to build cross-functional knowledge and skills.
· Identify training needs as necessary from time to time.
· Identify reporting needs, both on a production and ad hoc basis as is necessary to achieve business goals and results.
· Participate in committees relevant to functional duties.
· Provide other duties as necessary or required.
· BA/BS degree with at least five (5) years of relevant professional experience; or a Masters degree with at least six (3) years of relevant preferred.
· Minimum of two (2) to three (3) years of health care administration and/or managed care experience.
· Minimum of five years of credentialing experience in progressively more responsible positions.
· Minimum of two (2) years of managerial experience at the department director or manager level.
· Knowledge of the Facets claims system strongly preferred.
· Strong working knowledge of MS Excel, Word, and CACTUS software.
· Prior experience with regulatory bodies like MDCH and NCQA, including strong working knowledge of regulatory
standards and requirements related to credentialing.
· Direct experience with vendor oversight responsibilities.
· Highly developed project management skills required to identify business and process needs, and integrate complex
functions and/or highly diverse components of operational units.
· Extensive knowledge of provider credentialing documents, policies and procedures, including those required by
national accreditation organizations.
· Excellent oral and writing skills characterized by the ability to communicate thoroughly and clearly to a range
of reading and comprehension skill levels.
· Demonstrated ability to articulate goals, plan and implement processes to achieve those goals, recognize and
assess the implications of confounding variables, anticipate consequences, and
· Advanced interpersonal (e.g., mediating, counseling, mentoring), negotiating and management skills required
to manage critical internal and external relationships and activities that are diverse and complex.
· Extensive experience in evaluating, developing, and implementing operating procedures and systems affecting the
business environment, with the decision making authority to make changes.
· Demonstrated ability to work resourcefully and creatively, to think independently, and to exercise independent judgement in originating or developing complex techniques or programs in a complex and dynamic environment.
· Commitment to the corporate mission, vision, and values.
· High level of integrity as demonstrated by 1) appropriate treatment of confidential information, 2)vadherence to policies, procedures, rules and regulations, 3) professional conduct in dealing with persons internal and external to the organization, and 4) sensitivity to target populations.