This position is responsible for managing the operational, financial and personnel activities of the department to ensure compliance with all state, federal and regulatory standards. The manager for this department will ensure that all credentialed practitioners and entities are processed in accordance to health plan policy and that all elements of the credentialing process, as well as all other departmental functions, are carried out efficiently and thoroughly.
This position is full-time and resides at our Health Plan in Irving, TX.
Essential Duties and Responsibilities
- Oversee the credentialing process for all credentialed practitioners and entities. Ensure that all applicants meet the applicable, current criteria and that their applications or reapplications are processed in a timely, efficient and thorough manner in accordance to all policies, procedures and regulations.
- Identify and analyze the design of jobs, work processes, work flows, etc., for the department and implement appropriate changes to improve effectiveness, productivity and efficiency that support the overall goals of the department, including conducting audits as required of files, turnaround time, data entry, etc. Identify and implement process improvement initiatives as needed. Effectively coordinate, integrate, and communicate information and services within the department and with other departments, such as statistical information, credentialing criteria, etc.).
- Recruit, train and manage all team members within the department. Ensure continuous mentoring, training and development of each team member with continuous feedback and performance monitoring. Maintain professional growth and development through seminars, workshops and/or professional affiliations to remain abreast of latest developments and trends HMO credentialing. Ensure staff maintains current technology and knowledge through training and continuing education programs. Ensure that staff maintains required licensure or professional certifications, when applicable.
- Work in collaboration with CMCHP Quality, Information Systems, and other applicable departments to ensure compliance with all regulatory requirements related to credentialed practitioners, including, but not limited to: Triennial credentialing and recredentialing of HMO providers, Regulatory Readiness, oversight of delegated entities, NCQA standards.
- Prepare all materials required for the appropriate committee reviews (Credentials, Board of Directors, etc.) and ensure accuracy of data presented and follow up on all required information, requests, communication, etc.
- Update and maintain all policies and procedures related to credentialing and peer review. Ensure that all credentialing documents are kept up to date and are reviewed frequently.
- Oversee the support and record keeping for all Credentialing meetings unless supported by other areas deemed appropriate by the Senior Director of Network Administration. Oversee contracted services utilized by the department to ensure all aspects of the contract are fulfilled and all areas are in continuous compliance with all standards.
- Plan and manage annual budgets (operating, capital or any special type of budget) to carry out the goals and objectives that have been established by the department and ensure efficient and appropriate use of funds as outlined in Children's policies.
- Four-year Bachelor's degree or equivalent experience, required
Licenses & certifications
- Certification as a Certified Provider Credentialing Specialist (CPCS), required
- Five or more years’ experience in Credentialing, preferably in an HMO with at least two years’ experience in a leadership/management role, required.
Specific knowledge, skills and abilities
- Maintain effectiveness when experiencing major changes in work responsibilities or environment; adjust effectively to work within new work structures, processes, requirements, or cultures.
- Use appropriate interpersonal styles to establish effective relationships with customers and internal partners; interact with others in a way that promotes openness and trust and gives them confidence in one's intentions.
- Meet patient and patient family needs; take responsibility for a patient's safety, satisfaction, and clinical outcomes; use appropriate interpersonal techniques to resolve difficult patient situations and regain patient confidence.
- Ensure that the customer perspective is a driving force behind business decisions and activities; craft and implement service practices that meet customers' and own organization's needs.
- Develop and use collaborative relationships to facilitate the accomplishment of work goals.
- Identify and understand issues, problems, and opportunities; compare data from different sources to draw conclusions; use effective approaches for choosing a course of action or developing appropriate solutions; take action that is consistent with available facts, constraints, and probable consequences.
- Take prompt action to accomplish objectives; take action to achieve goals beyond what is required; be proactive.
- Deal effectively with others in an antagonistic situation; use appropriate interpersonal styles and methods to reduce tension or conflict between two or more people.
- Effectively manage one's time and resources to ensure that work is completed efficiently.
- Accomplish tasks by considering all areas involved, no matter how small; showing concern for all aspects of the job; accurately checking processes and tasks; being watchful over a period of time.
- Set high standards of performance for self and others; assume responsibility and accountability for successfully completing assignments or tasks; self impose standards of excellence rather than having standards imposed.
- Assimilate and apply new job-related information in a timely manner.
- Clearly convey information and ideas through a variety of media to individuals or groups in a manner that engages the audience and helps them understand and retain the message.
- Sedentary - Exerting up to 10lbs. occasionally or negligible weights frequently; sitting most of the time.