Manager Credentialing - JHP

Job Details

Job Description

Essential Functions:

• Proficient in credentialing software, databases and Microsoft Office Suite.
• Ensure that JHP/HPP/Enterprise, NCQA, Federal, State and other regulatory requirements are met.
• Monitor team production and goals on a daily, weekly and monthly basis and actively address individual production concerns and barriers to meeting metrics.
• Serve as the lead on all credentialing related matters, including audits, NCQA surveys, annual HEDIS audits and regulatory requests.
• An understanding of the healthcare industry, healthcare regulations under NCQA, CMS and the Joint Commission as well as an understanding of Primary Source Verification.
• Prepares and delivers performance appraisals, working through all issues and managing performance in a way that provides the highest level of productivity and quality across the team.
• Directs & mentors' staff in a constructive and positive manner to foster employee relationships and development.
• Maintain and foster a strong and collaborative relationship with internal and external customers.
• Develop and maintain procedures and best practices for efficient and timely processing of credentialing/recredentialing applications.
• Manage relationship with external Credentials Verification Organization (CVO) to ensure files are being processed timely and accurately. Serve as primary point of contact to the CVO for all provider or internal source complaints and handle appropriately to resolution. Review all monthly reports from CVO to assure all performance standards are being met. Manage productivity with CVO to assure all work is being returned within contractual timeframes.
• Serve an active role on credentialing and Quality Management Committee (QMC) committees, providing subject matter expertise, direction and support, as it relates to credentialing.
• Communicates regularly with the external Manager(s) of delegated relationships in the oversight of credentialing/recredentialing programs at all agencies and/or subcontractors with whom Jefferson Health Plans (JHP)/Health Partners Plans (HPP)delegates credentialing, including initial evaluation and approval. Serve as the subject matter expert on credentialing to JHP/HPP's Delegated Vendor Oversight Subcommittee, assisting in audits when required.
• Provide timely first level resolution to issues and/or questions relating to the credentialing/recredentialing process.
• Establish procedures to refresh and reconfirm existing provider data on a routine basis, particularly with large provider groups and contracts.
• Review all audits and address errors with staff. Identify error trends, working with communication/documentation specialist to re-educate team and modify materials if needed
• Assure quality network of practitioners/providers through consistent application of JHP/HPPs Credentialing/Recredentialing policy requirements.
• Oversee the maintenance of production reports, letters, and the recredentialing schedule of practitioners as well as all regulatory reports.
• Provide status, issues, recommendations and risk exposure to management.
• Keep current with rules, regulations, policies and procedures related to credentialing/recredentialing and sanctions.
• Manage budget and control expenses while meeting operational, financial and service requirements.

Education:

• High School Diploma or equivalent required, associate's degree in health/business administration preferred.
• Seven years credentialing experience required.
• CPCS Certification preferred.

Skills/Abilities:

• Detailed knowledge of NCQA, Federal, State and other regulations required with direct experience in credentialing audits and NCQA surveys.
• Strong provider data knowledge with deep understanding of hierarchy of data and standard approaches to data setup required.
• Experience in managing cross functional teams in credentialing/recredentialing of practitioners and providers preferred.
• Strong interpersonal skills, oral and written communication, and presentation skills required.
• Demonstrated ability to drive process improvement and quality within a team environment preferred.
• Detailed Knowledge of NCQA, Federal, State, and other regulations required with direct experience in credentialing audits and NCQA surveys preferred.
• Process and project management ability required.

Work Shift

Worker Sub Type

Primary Location Address

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

Benefits

At Jefferson, we offer a comprehensive total rewards package designed to support the health and well-being of our colleagues and their families. It includes a wide range of benefits including competitive pay, health and retirement benefits, life and disability insurance, paid time off, educational benefits, financial and mental health resources and much more. Our diverse benefits offerings ensure you have the coverage and access to services you need to thrive both personally and professionally.