The Director of Credentialing and Managed Care Contracting is responsible for overseeing the Credentialing department and Managed Care Contracting by demonstrating a comprehensive knowledge of regulations, standards, and practices required to achieve and maintain licensure, credentials, and managed care contracts. The position requires a thorough understanding of medical policy, managed care contracts, and the ability to effectively interact with medical professionals, office personnel, and other stakeholders.
- RESPONSIBILITIES OF THE JOB AND ESSENTIAL ELEMENTS:
Direct Duties:
- The position shall be responsible for the following:
- Maintain compliance with all regulatory and accrediting institutions
- Design and maintain the development and enhancement of internal credentialing and managed care contracting processes.
- Release information to agencies and members of the public as required by law
- Monitoring and ensuring credentials documents are maintained and current.
- Interacts with varied levels of management, physician office staff and physicians effectively to accomplish credentialing and various elements of implementation and launch.
- Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.
- Maintains confidentiality of provider information.
- Provides enrollment with government and commercial payers.
- Monitoring and ensuring credentials documents are maintained and current.
- Data entry and follow up in credentialing software.
- Use payer credentialing systems and manage payer contracts.
- Release information to agencies and members of the public as required by law.
- Maintain a contract repository with rate sheets for revenue cycle staff.
- Develop and negotiate managed care contracts with payers.
- Monitor contract performance and compliance.
- Analyze financial and operational impact of contracts.
- Maintain relationships with managed care organizations.
- Ensure contracts align with organizational goals and regulatory requirements
- Payer negotiation and rate modeling.
- Other duties as assigned.
Other Responsibilities:
- Displays a competent knowledge of Agency policy and procedures as well as Federal and State Regulations. Keeps current with available resources.
- Maintains confidentiality, proper boundaries and an ethical relationship with clients and co-workers accordingly to Company's policies.
- Ensures all provider records are maintained according to agency standards, policies and procedures.
- Completes annual educational program as required.
- Participates in the development of quality improvement activities designed to enhance agency and program services
- Performs Other Duties as Needed
- MINIMUM EDUCATION AND EXPERIENCE QUALIFICATION REQUIREMENTS:
- Minimum 7 years' experience in similar healthcare role.
- Strong ability with Microsoft products: Outlook, Word & Excel.
- Excellent verbal and written skills.
- Ability to interact professionally and pleasantly with all customers.
- Strong team player.
- Knowledge of CMS regulations.
- High level of attention to detail with exceptional organizational skills.
- Strong knowledge of healthcare billing operations.
- Able to work independently with minimal supervision and to set priorities in the completion of daily tasks and project deadlines.
- Assist in managing the flow of information between the payers.
- Demonstrated skills in problem solving and analysis and resolution.
- Ability to communicate appropriately and effectively with practitioners and providers, including sensitive and confidential information.
- Ability to problem solve and explore all options and to use available resources to find new and effective solutions.
- Prioritize and meet deadlines on an ongoing basis to ensure timely completion according to process requirements.
- Excellent time management skills.
- Capacity to work under pressure.
- Experience working in a professional and confidential environment.
- Ability to excel with change and respond appropriately even in challenging situation
REQUIRED SKILLS:
- Ability to deal with diverse populations
- Ability to stay within boundaries of the role and function of position
- Critical thinking skills
- Organizational skills
- Communication skills
- Ability to evaluate and comprehend techniques, procedures and changes to meet variable situations
- Able to effectively communicate with supervisors and directors to improve his/her skills and adapt to Agency culture and policies.
Requirements:
This is a remote position. The salary range for this position is $120,000 to $150,000 annually, commensurate with experience.