• Ensure credentialing processes are in compliance with professional standards, bylaws, state and federal regulatory requirements with such organizations such as the National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid (CMS), Utilization Review Accreditation Commission (URAC). 

• Develops credentialing and privileging policies and procedures. Reviews policies to assure incorporation of regulatory changes; and recommends changes, revisions and enhancements as needed in accordance with best practices. 

• Oversees and supports the day-to-day operations of Credential/Privileging processes. 

• Facilitates the implementation of credentialing committee recommendations and follow-through. 

• Oversees and maintains credentialing database; generates reports and prepares audits as requested.

• Function as primary contact for all internal and external inquiries regarding Credentialing and Privileging, and potential and/or existing practitioners regarding credentialing. 

• Act as a liaison between department and clinical areas 

• Identifies opportunities to improve processes and systems. 

20% Strategic Planning 

• Advises organization leadership on changing regulatory requirements and implications for our business model. 

• Reviews and responsible for providing oversight and management of department budgeting and forecasting, goals, and initiatives. 

• Provides feedback regarding provider licensing, privileging, and regulatory planning for all new sites and acquisitions. 

20% Department Management 

• Provides day-to-day supervision of staff with ongoing feedback and evaluation of work performed, including hiring, terminations, annual performance reviews and staffing needs. 

• Acts as a role model and serve as a leader and resource for staff. 

• Provides training of new employees and cross-training to provide coverage when staff is absent, or workload demands 

• Serves as facilitator and essential link between health plans to ensure patient access and claim(s) reimbursement 

• Oversees for the submission of provider information to health plans for inclusion in health plan networks. 

• Oversees the notification to health plans of provider terminations and reassignment of membership when applicable. 

• Oversee the notification to health plans of provider information/demographical updates and changes as well as practitioner panel changes. 

• Responsible for monthly, quarterly, and semi-annual reporting of credentialing activities to health plans. 

• Bachelor’s degree in business or related field, or equivalent experience.  

• Minimum of three to five years of supervisory experience.  

• Minimum of five years in a Credentialing/Medical Staff environment.  

• Excellent working knowledge of PECOS, CAQH and NPI Data Base