Medical Staff Credentialing Director jobs in Harrisburg, PA

Administrator Managed Care Credentialing

I. Position Responsibilities

• Perform credentialing and re-credentialing applications for Health Plans and other payors according to plan specifications while keeping within company policies on content of the information disclosed

• Process, track and file credentialing applications within established standards and in a timely manner to meet Payor Plan specifications

• Familiarity with Online Portals such as Availity and Tricare and United, in addition work with Certified Verification Organizations (CVO’s) on regional credentialing

• Maintain up to date provider information stored in CAQH repositories for health plans to access to verify primary and secondary source documents

• Respond to information requests from payors for updated documentation or questions on recent credentialing submissions

• Verify that Credentialing Applications have been received and verify that credentialing applications have been approved in a 60 to 90 day time frame

• Update and distribute facility rosters of facilities as needed

• Maintain a facility database of all centers in PAM Health System with all up to date relevant ID information on each center including NPI and TID and Legal Names, etc.

• Communicate with facilities, legal, CBO, payors, and other third parties to secure needed information and documents for credentialing

• Upload contracts, amendments, and other payor documents in Cobblestone Contract Management System as requested

• Train new Managed Care employees on Cobblestone use

• Admin for Dept of Labor Office of Workers Comp Programs in all registered facilities and process requests for access to facility specific portals

• Register and maintain files for facilities to remain in-network with DOL OWCP

• Update and distribute DOL OWCP roster as needed

• Distribute phone and email contract requests to the appropriate Regional Managed Care Director for Follow-up

• Collaborate with the PAM legal dept. what we are able to provide on Ownership Disclosure Forms for Health Plans

• Collaborate with PAM Health Risk Manager on maintaining a database of Malpractice and Liability Lawsuits

• Handle all aspects of Voyages Behavioral Health Credentialing in the two new Psychiatric centers in Texas

• Monitor and Managed the “Managed Care Credentialing” email box for recredentialing notices that went to PAM Facilities

II. Customer Service

• Maintains the highest level of customer service via courtesy, compassion and positive communication.

• Promote communication and follow-up with internal and external stakeholders

• Is sensitive to meeting deadlines for Credentialing documentation from Health Plans

• Promotes the mission and vision of PAM Health within the work environment and the community.

• Respects dignity and confidentiality by adherence to all applicable policies and procedures.

III. Health and Safety

• Works in a manner that promotes safety; wears clothing appropriate to the performance of the job.

• Participates in OSHA required training.

• Follows universal precautions as appropriate for position; complies with Employee Health requirements for continued employment.

• Reports unsafe practices to management.

• Knows own role in case of an emergency.

POSITION QUALIFICATIONS:

Education and Training: Bachelor’s Degree

Experience: 3 plus years of experience in a credentialing role as a Provider or in a Managed Care Organization Credentialing Position or with a Certified Verification Organization

Knowledge, Skills, and Abilities:

• Understanding of Quality and Performance documents required during credentialing process including accreditation and certification materials

• Knowledge of requirements and in-house programs to perform Delegated Credentialing and experience with Certified Verification Organizations

• Some knowledge of Post Acute Care services and Care Settings

• Basic knowledge of Health Plan Lines of Business and coverages including Managed Medicaid/Medicare Advantage/Commercial Health Insurance/Workers Compensation/Affordable Care Act Exchange

• Willingness to work remotely in a home based arrangement

• Experience with working with “The Council for Affordable Quality Healthcare, Inc (CAQH)”.

PHYSICAL DEMANDS: See attached Job Activity Requirements

WORKING CONDITIONS: Working generally indoors in well-lighted, well-ventilated areas. Working conditions as in hospital surroundings. The position will be working from home and need to work regular business hours of 8am to 5pm est.

ORGANIZATIONAL DATA: This is an exempt position, supervised by the SVP of Managed Care.

The above statements are intended to describe the general nature and level of the work being performed. They are not intended to be construed as an exhaustive list of all responsibilities, duties, and skill required of personnel so classified.