Responsible for the Children's Health provider payor credentialing and enrollment process. Supported providers include organizational providers such as Children’s Medical Center facilities and ancillary services, as well as individual practitioners performing on behalf of Children’s Health affiliate organizations. Ensure that all applicable providers are fully credentialed with Texas Medicaid, state-sponsored managed care plans, and commercial health plans. Work collaboratively with Children’s Health affiliate Directors as well as Children’s Health internal departments (e.g., Patient Financial Services, Compliance, Medical Staff Services). Ensure compliance with NCQA standards, directs the NCQA Credentialing certification and biannual re-certification process and maintains the credentialing Policies and Procedures. Facilitate the Credentials Committee, directly supervise Managed Care Credentialing Coordinators, develop strategic departmental goals to reduce delays in network participation and establish and maintain delegated credentialing agreements.
- Typically manages professional staff and/or team leaders over multiple teams.
- Typical span of control: Administrative 8-10, Clinical 10-13, Support Services 11-13; e.g. Admin: Fin, IT, Legal, HR, Public Affairs; Support Services: EVS, Security, Engineering, Food Services.
- Accountable for the performance and results of a team or multiple teams within own discipline.
- Adapts unit plans and priorities to address resource and operational challenges.
- Provides guidance, coaching, and feedback to team leaders on effective management techniques.
- Makes employment decisions for the team, seeking direction from more senior leaders on more complex situations.
- Decisions are guided by policies, procedures, and functional priorities; receives guidance from a higher-level manager on high-impact decisions.
- Monitors quality metrics and changes in practice that impact clinical, financial, or operational outcomes and develops action plans to address areas for improvement.
- Provides guidance to others as needed for non-routine and/or complex problems/situations.
- Monitors and manages a budget for defined area of responsibility.
JOB SPECIFIC RESPONSIBILTIES:
- Oversee the payor enrollment process with all applicable government plans for Children's Health facilities and ancillary services, as well as individual practitioners serving on behalf of Children's Health provider groups. Coordinate the gathering and verification of necessary data, working directly with providers or appropriate representatives. Complete applications accurately and thoroughly, meeting standards set forth by CMS. Obtain application signatures from the authorized signatory and provide all required supporting documentation. Submit applications and follow up diligently to ensure progress. Respond to deficiency notifications in a timely manner. Attain, verify, and disseminate state required billing numbers and approval letters as needed.
- Oversee the commercial and Medicaid Managed Care plan participation for Children’s Health facilities and ancillary services, as well as individual practitioners serving under Children's Health provider groups. Submit all payor-specific forms and required documentation to health plans as required. Verify accuracy of health plan directories. Follow up diligently on provider addition requests and communicate provider changes, corrections, and terminations.
- Obtain, verify, and maintain complete and accurate demographic information, accreditation, and certification documentation for Children's Health organizational and individual providers. Maintain current copies of certificates (licensure, DEA, DPS, pharmacy, etc). Serve as a primary administrator for the Echo credentialing database for Managed Care purposes. Maintain the accuracy of provider CAQH profiles and coordinate re-attestation every 120 days.
- Establish department policies and procedures consistent with NCQA standards. Develop and maintain a Managed Care Credentialing and Provider Enrollment Manual, which includes detailed instructions on payor-specific application requirements for participation with Medicare, Medicaid, and commercial health plans. Continuously analyze the effectiveness of the current credentialing process and create departmental strategies for reducing delays in participation.
- Serve as liaison between health plans and Children's Health support departments in resolution of issues related to credentialing and plan participation. Stay abreast of insurance terms and regulatory changes by researching legislation and state requirements. Research accrediting organization requirements. Serve as an educational resource on the subject of credentialing and payor-specific participation requirements. Create, maintain, and disseminate plan participation status and billing information to hospital, affiliate provider groups, and all applicable Children’s Health internal departments to maximize collections in the revenue cycle management process.
- Establish and maintain delegated credentialing agreements with all applicable contracted payors. Analyze and negotiate all delegated credentialing agreements within approved guidelines. Facilitate workgroups to establish processes and workflows as required by delegated credentialing agreements. Create contract summary documents and provide education/training for the appropriate departments.
- Supervise designated staff within the Managed Care department who are responsible for credentialing and enrollment. Assign tasks and projects to direct reports. Ensure that staff is completing work accurately and by required due dates. Responsible for orientation and training of new staff. Collaborate with Director on any personnel issues, including feedback sessions, counseling and performance reviews.
- Minimum of five (5) years of experience in Payor Relations or Credentialing with an insurance company, hospital, or other large group of providers, required.
- Minimum of five (5) years’ experience managing staff, required.
- Four-year Bachelor's degree or equivalent experience, required.
LICENSES AND CERTIFICATIONS:
- Certification as a Certified Provider Credentialing Specialist (CPCS), preferred.
SPECIFIC KNOWLEDGE, SKILLS, & 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.
- 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.
- Provide feedback, instruction, and development guidance to help others excel in their current or future job responsibilities; plan and support the development of individual skills and abilities.
- 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.