ESSENTIAL FUNCTIONS:

• Function as primary credentialing contact to all internal and third-party credentialing entities such as health plans, Medicare, Medicaid; develops and maintains positive working relationships.

• Develop processes, instruction sheets and training materials for the department.

• Perform credentialing, privileging, re-credentialing, and re-privileging of Licensed Physicians and Advanced Practice Practitioners, and other licensed or certified staff as needed.

  • Ensure completion of verifications of license, registration, certification, education, training, insurance, affiliations and experience at initial appointment and reappointment in accordance with Alpine policies and federal regulations.

  • Ensure that Credentialing Committee receives pertinent credentialing and privileging information to allow them to grant or deny credentialing and privileging.

  • Ensure the credentialing process for commercial insurers and Medicare/Medicaid enrollment and reassignment of benefits is performed in an accurate and timely manner.

• Maintain confidential credentialing files and provider database ensuring completeness, accuracy, and confidentiality.

• Communicate with the Medical Directors, Provider Recruiter, providers, and Billing Department regarding credentialing and privileging. Coordinate with outside organizations and community stakeholders to ensure positive and mutually beneficial relationships.

• Maintain open communication with the provider staff, Medical Directors, and Administration to identify and work to solve problems as they arise. Bring problems to the attention of Medical Directors as they arise.

• Routinely communicate updates across organization as appropriate on new policies and procedures, new plan participation, etc.

• Ensure all providers are accurately and timely loaded in all health plan systems through various vehicles including regular meetings, roster reconciliations, targeted problem resolution.

• Support organization in payor relations and issue resolution.

• Coordinate ad hoc Credentialing Committee meetings.

• Remain well informed of current credentialing and privileging rules and requirements and ensure compliance with those rules and regulations.

• Prepares for and coordinates credentialing audits in compliance with the managed care delegated credentialing contracts and other state and federal agencies as appropriate.

• Coordinates the management of the expirables process to ensure all contracted provider licenses and certificates remain current, and appropriate notification is provided prior to expiration.

• Oversee day-to-day credentialing and privileging operations ensuring adherence to policies and procedures.

• Serve as primary escalation point for internal business partners, credentialing specialists, providers, and payors in the resolution of issues.

• Identify creative solutions to complex situations and operational problems to improve efficiency and engagement.

• Manage credentialing requests and action items (tasks) as needed to support team capacity.

Supervise Credentialing personnel, which includes work allocation, training, promotion, enforcement and auditing of internal procedures and controls, and problem resolution; evaluates performance and makes recommendations for personnel actions; motivates employees to achieve peak productivity and performance.

REQUIREMENTS:

• Bachelor’s degree preferred or commensurate experience.

• 7 years of management experience

• 10 years of credentialing experience

• Credentialing Certification through an Alpine approved organization is preferred. Certification is required within 3 years from the start date of this position. Extension of this requirement may be granted at the sole discretion of Management.

• Ability to build professional cross functional working relationships among all levels of the organization.

• Ability to make valid judgments, formulate recommendations or action plans, and evaluate the effects of decisions and actions.

KNOWLEDGE, SKILLS, ABILITIES:

• Intermediate computer skills including Microsoft Office; especially Word, Excel, and PowerPoint.

• Excellent customer service and interpersonal skills including the ability to interact effectively and professionally with individuals at all levels; both internal and external

• Exercises sound judgment in responding to inquiries; understands when to route inquiries to next level.

• Self-motivated with strong organizational skills and superior attention to detail

• Must be able to manage multiple tasks/projects simultaneously within inflexible time frames. Ability to adapt to frequent priority changes

• Team player that develops strong collaborative working relationships with internal partners and can effectively engage and ability to build consensus among cross-functional teams