Director, Credentialing

Summary :

• Manage the credentialing process for all medical staff providers, in accordance with The Joint Commission, NCQA, and CMS accreditation standards, and Federal and State Laws.
• Responsible for credentialing analysis, quality assurance, planning, client / vendor relationships and continuous improvement of operational performance.
• Accountable to drive, monitor, and enhance oversight of quality, analytics, and auditing of vendor (Cognizant and other) performance to ensure contractual adherence in both operational and compliance SLAs, quality and timeliness standards.
• Oversee validation of vendor performance reporting and daily operations.
• Accountable to drive, monitor, and enhance Credentialing Delegation oversight, including onboarding of delegates and performance management in synchronicity with regulatory and enterprise policies.

Implement process initiatives in alignment with regulatory and enterprise requirements as needed. Develop standardized enterprise processes that incorporates regulations and requirements for EmblemHealth's Family of Companies.

Lead and participate in system configuration and new product or process initiatives. Serve as a deciding body in all phases.

Execute process and policy changes in accordance.

Responsibilities :

• Analyze and implement process improvements to enhance efficiency of credentialing.
• Conduct on-going program evaluations and audits of data integrity.
• Ensure accurate outcomes and compliant procedures to meet service goals.
• Coordinate with practice management, licensing agencies, insurance carriers, and other appropriate organizations to complete credentialing and re-credentialing applications
• Manage staff including interviewing and selecting qualified candidates, coaching for career development, training, monitor productivity and accuracy, conduct performance evaluations, guidelines and changes, consistent application of HR policies and procedures, and guide staff to confident decision-making.
• Support, participate and contribute to the development and growth of credentialing functions.
• Work with various departments to ensure a smooth transition of providers when on-boarding, for new contracts and during acquisitions.
• Drive and monitor oversight of vendors' (Cognizant and other) quality performance for each core process of Credentialing and Delegation to meet contractual requirements and align with regulatory mandates and enterprise-wide (EH and CCI) customer experience objectives and overall corporate strategic direction.

Validate and trend reported quality performance results through independent reporting and audit-the-auditor reviews.

Quantify and validate vendor quality performance by conducting and monitoring on-site and transactional audits, policy and procedure verifications, quality program verifications, adhoc reporting and compliance adherence reviews.

Monitor regulatory execution and reporting for sanction and exclusion processing and OMT reporting.

Lead and develop direct reports to continuously conduct on-site and transactional audits, ad-hoc reporting and compliance adherence reviews.

Participate and coordinate in regulatory audit response preparation and audit conveyance. Develop and maintain policy and procedure documentation in accordance with current processes.

Participate in Credentialing / ReCredentialing Committee meetings, ensuring vendor participation and preparation, and converse with Medical Directors as needed.

Ensure preparedness for and participate in Monthly Delegation Oversight Committee (DOC) Meeting.

Identify opportunities for process improvement, systematic enhancements, and standardization of departmental practices across the enterprise of initial and re-credentialing, regulatory compliance and delegated credentialing oversight.

Work with all levels of management and staff to implement changes that enhance the customer experience and operational workflow in support of enterprise objectives.

• Lead and participate in internal and external interdepartmental meetings to maintain and expand business process efficiency, issue management and staff education or training.
• Proactively and clearly communicate milestones, status, selling of ideas and proposals. (use Executive Briefing Tool

Requirements :

• BS or BA degree required
• Certified Provider Credentialing Specialist (CPCS) and Certified Professional in Medical Staff Service Management (CPMSM) is preferred
• 10+ years of relevant professional experience in credentialing and 7 years in a leadership capacity required
• 5+ years of experience in Quality Mgmt. & Improvement, Change Management, and Customer Experience preferred
• Track record of successfully managing large, high impact projects preferred
• Ability to lead, develop, mentor, and manage staff to achieve departmental and organization goals and objectives required
• Knowledge of delegated credentialing and verification, and related accreditation and certification, requirements required
• Knowledge of medical credentialing procedures and standards required
• Extensive experience with and knowledge of CAQH and credentialing processes required
• Energy, drive and passion for End-to-End excellence and customer experience improvement required
• Excellent collaboration skills and the ability to influence management decisions required
• Strong problem solving and analytical skills that can be applied across all types of business problems required
• Strong communication skills (verbal, written, presentation, interpersonal, facilitation) required
• Solid coaching and mentoring skills to continuously develop staff core competencies at vendors required
• Demonstrated Customer Experience focus and 1 year of process improvement experience required
• Ability to work with physicians in a collaborative manner required
• Ability to create, implement, document and audit policies and procedures required
• Ability to manage direct / indirect / remote employees to ensure internal controls are followed required
• Ability to effectively prioritize and execute tasks in a high-pressure environment required

Additional Information

Requisition ID : 24036

Hiring Range : $105,000-$195,000