Payer Credentialing Operations Lead-Hybrid-CT, MA or NY

Payer Credentialing Operations Lead-Hybrid-CT, MA or NY

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Job Description

Provides support for payer/managed care, Medicare and Medicaid Enrollment operations by organizing the functions relating to the credentialing process for all applicable practitioners as identified. This position is responsible for monitoring Credentialing delegated activities while adhering to Connecticut Children’s Medical Center, federal and state regulatory/accreditation requirements and standards. Coordinates, conducts, and documents delegation and site visit assessments as necessary to comply with state, federal, NCQA and any other applicable requirements.

Requires a fundamental understanding of the insurance credentialing process and terminology related to the job.

Responsibilities

• Coordinate with Subject Matter Experts and delegate, obtaining clarification on regulatory requirements.
• Develops corrective action plans when deficiencies are identified and documents follow-up to completion.
• Prepares status reports for submission to Delegated Entities.
• Ensures compliance with reporting requirements by tracking the receipt and completeness of reports.
• Responsible for meetings, including the preparation of documents for committee oversight of delegated functions.
• Works with contracting, Medical Staff management, vendor management and legal to develop and maintain delegation agreements and assessment tools.
• Prepares delegation oversight document evidence for monitoring visits and NCQA accreditation surveys and participates on Connecticut Children’s Medical Center's work team.
• Coordinates and maintains audit schedules that adhere to required turnaround times for delegation and audits. Assist with preparing and collecting all information needed.
• Process provider initial and re credentialing applications in accordance with Connecticut Children’s Medical Center, federal, NCQA and state regulatory/accreditation requirements and standards.
• Perform other duties as assigned by management.
• Performs Quality Control audits of completed initial and re-credentialing applications using Connecticut Children’s Medical Center internal file audit process.
• Assures that standards of practice and policies are in compliance with Connecticut Children’s Medical Center contractual requirements and other regulatory guidelines and standards.
• Monitors enrollment status reports for accuracy.
• Assists with Medical Staff applications and other Medical Staff tasks as needed.
• Other duties as assigned.

Qualifications

Experience

Required:

Minimum 3 Years Of Provider Credentialing And/or Enrollment Experience.

2 years’ experience completing delegation oversight assessments/audits.

LICENSE And/or CERTIFICATION REQUIRED

Certified Provider Credentials Specialist (CPCS) preferred on hire or obtain one of these certifications within 2 years of hire:
Certified Professional Credentials Specialist (CPCS) or Certified Professional in Medical Staff Management (CPMSM)

Position Specific Job License And/or Certification Required

N/A

Knowledge,

Skills And Abilities

Required

KNOWLEDGE OF:

Knowledge of regulatory/accreditation requirements and standards (TJC, CMS, DOH, HIPAA, NCQA).

Understanding of program and provider enrollment and credentialing regulations and requirements preferred.

SKILLS:

Detailed-oriented and analytical maintain accuracy in a documented process

Must have excellent verbal/written interpersonal/communication skills and experience at all levels.

Computer knowledge of credentialing database software.

PC proficiency, proficiency in Microsoft Office applications and ability to effectively utilize other software and systems as needed.

ABILITIES:

Ability to establish and maintain positive relationships, building trust and respect by consistently meeting and exceeding expectations

About Us

Connecticut Children’s is the only health system in Connecticut that is 100% dedicated to children. Established on a legacy that spans more than 100 years, Connecticut Children’s offers personalized medical care in more than 30 pediatric specialties across Connecticut and in two other states. Our…