The Manager, Provider Data Management and Credentialing is responsible for developing, managing and monitoring processes and procedures that support the credentialing and re-credentialing processes. The individual is directly accountability for data reporting, and planning and coordination of efforts with other departments to ensure effective operations of the Credentialing and Provider Data Management department. The individual oversees all of the credentialing and re-credentialing functions; including application processing management, primary source verification and compliance with guidelines or requirements mandated by NCQA, provider contracts and state regulations. The individual maintains oversight of the integrity and quality of the provider data while tracking patterns.
General Duties & Responsibilities:
- Manage and report on provider data integrity, accuracy, and trends and provide recommendation.
- Provide feedback regarding accuracy internally and to outsourcing partners.
- Oversees calibration of quality assurance functions.
- Ensure deactivations are appropriate and completed in a timely manner.
- Report team performance metrics identifying and implementing improvements to increase and maintain productivity and effectiveness.
- Ensure Delegated Credentialing data is maintained and accurate.
- Establish annual and long-range data management and compliance goals, define data management and data security strategies, reporting mechanisms and program services.
- Lead the development and implementation of effective and reasonable policies and practices to secure protected and sensitive data.
- Collaborate with various cross-functional departments on complex and escalated issues to identify, report on and implement solutions.
- Oversee enrollment and credentialing of Providers in accordance with requirements (NCQA, etc.).
- Ensure One Call's credentialing process meets client expectations and state regulations.
- Assist with delegated credentialing audits as needed.
- Ensure all applications and data contained are tracked.
- Ensure that initial and recredentialing process and goals are meet NCQA guidelines.
- Ensure reports and minutes are prepared accurately, timely and work to automate the reports where applicable.
- Oversee provider credentialing committee facilitation activities.
- Participate in the determination and implementation of credentialing related corrective action plans.
- Oversee agenda and minutes and Conduct Final review of Credentialing Files, prior to Committee.
- Provide recommended solutions to credentialing issues and changes in requirements.
- Aid in answering Request for Proposal (RFP) questions.
- Provide consultative services to proactively meet customer needs, using management reports and trend analysis.
- Organize workflow between other departments to ensure efficient and accurate outcomes.
- Coordinate and implement appropriate performance management strategies for team members to include:
- Assist in the hiring process, including interviewing candidates.
- Assist, train and motivate team members.
- Responsible for attendance and company approved time off for team members.
- Participate in the determination and implementation of Performance Improvement Plans and performance management initiatives.
- Create efficiencies with the department.
- Update management team as appropriate on major issues, both internal and external.
- Other duties as assigned.
Educational & Skill Requirements:
- Bachelor's in Business Administration or other related discipline is preferred; or equivalent combination of education and experience that is required for the specific job level.
- Requires a minimum of 3 years of experience in a leadership role.
General Knowledge, Skills & Abilities:
- Ability to investigate and analyze information and draw conclusions.
- Ability to develop and deliver presentations.
- Ability to process computer data and to format and generate reports.
- Ability to supervise and train employees, to include organizing, prioritizing, and scheduling work assignments.
- Ability to communicate effectively, both orally and in writing.
- Skill in developing policy and procedure documentation.
- Ability to plan, assign, train, supervise and evaluate the work of others, and to monitor goals, objectives, deadlines and priorities.
- Extensive knowledge of credentialing procedures and governing bodies standards.
- Ability to establish and maintain effective and cooperative working relationships with staff and others contacted in the course of the work.
- Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position.
- Ability to think and work effectively under pressure and accurately complete tasks within established times.