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                    Director, Credentialing

                    NEA's Member Benefits Corp
                    Islip, NY 11751
                    Full-time, Part-time
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                    Job Description

                    naviHealth™ is proud to be an equal opportunity/affirmative action employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, disability, or protected veteran status.

                    Posted Date 2 days ago (6/30/2020 7:11 PM)

                    Job ID 2020-3330

                    Job Locations US-TN-Brentwood

                    Category Legal and Compliance

                    Type Full Time - Benefits Eligible 30+

                    # of Openings 1


                    Job Summary

                    The Director, Credentialing will establish and oversee the process for ensuring credentialing and facility access requirements meet CMS and regulatory standards, within facility timeline expectations for clinician authorization processing. The Director will work collaboratively with management, compliance and credentialing team members to ensure completion of all credentialing with the insurance carriers is completed in a timely, efficient manner.


                    • Establish and maintain a Credentialing Department that will serve enterprise credentialing needs related to post-acute care, home based medical care, and any other future line of business.
                    • Oversee credentialing team and operations, to ensure processing of credentialing and facility access applications are performed accurately and efficiently.
                    • Develop program components including processes/policies/procedures which are compliant with regulatory, client and NCQA requirements.
                    • Manage and maintain integrity of credentialing systems. Ensure confidentiality of records.
                    • Maintain a departmental roadmap that aligns with compliance and CMS standards.
                    • Lead credentialing system implementation, and ongoing system management:
                      • Ensure business requirements align with credentialing systems.
                      • Manage integration and data point development.
                      • Oversees preparation and accuracy of credentialing reports.
                      • Ensure credentialing system aligns with Data Governance committee policies and standards.
                    • Establish and monitor credentialing metrics to improve credentialing and authorization performance.
                    • Conduct and maintain primary source verification; own contract relationship with CVO as applicable. Oversee the following:
                      • Obtain and evaluate information from primary sources to validate compliance with accreditation and regulatory standards.
                      • Recognize, investigate, and validate discrepancies and adverse information to ensure that review and approval bodies have the information needed to make informed authorization decisions.
                      • Verify and maintain licensing expirations using proper verification sources to ensure compliance.
                      • Provide prompt responses to naviHealth clinicians, field leadership and providers/practitioners to assist in completing the credentialing and authorization process.
                      • Ensures the confidentiality of integrity of credentialing files.
                    • Primary liaison with the organization's credentialing committee. Ensures:
                      • Files are reviewed that that do not meet credentialing criteria.
                      • Accurate/complete documentation about credentialing files in meeting minutes.
                      • Appropriate applicant communication & follow up throughout the credentialing process.
                    • Ensure credentialing and authorization legal, quality and audit requirements are met, to include conducting internal team reviews/audits, audits performed in conjunction with the compliance team, and participation in regulatory surveys.
                    • Maintain awareness and accurate interpretation of naviHealth credentialing policies, procedures, rules, and regulations.
                    • Ensure compliance with contractual obligations.
                    • Maintain current working knowledge of all regulations, statutes, laws, and standards.
                    • Develop, maintain, and distribute Clinician requirements reports to Compliance.


                    • Bachelor's degree in health administration, public administration, business or related field preferred.
                    • Minimum of 7 years' experience in credentialing, managed care, medical staff services, health services or government assistance programs.
                    • Leadership/supervisory experience preferred. Prior experience overseeing medium-to-large scale project(s) highly
                    • Current Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Staff Management (CPMSM) with the National Association of Medical Staff Services preferred.
                    • Business acumen and insight into clinical processes.
                    • Demonstrated customer service and organizational skills; customer-facing experience a plus.
                    • Strong computer skills to include proficiency in Microsoft Word, PowerPoint, Excel, and Visio.
                    • Excellent written and verbal communication, professional writing, and presentation skills.
                    • Excellent interpersonal skills in working with colleagues, other departments, and customers; able to interface effectively with all levels of individuals.
                    • Ability to maintain confidentiality.
                    • Ability to plan, assign, supervise and evaluate the work of others, and to monitor goals, objectives, deadlines and priorities.
                    • Ability to work in a fluid, fast-paced environment and remain appropriately detail-oriented.
                    • Ability to understand how all parts of the business interact across the organization.
                    • Ability to learn quickly in rapidly evolving work environment.
                    • Independent thinker and ability to work autonomously.

                    About naviHealth

                    naviHealth is improving the healthcare experience for seniors to live more fulfilling lives. For nearly a decade, naviHealth has been a trusted partner for the nation's top health plans, health systems, and at-risk physician groups navigating the shift from volume to value. Powered by a predictive technology and decision support platform that provides clinicians and care teams with evidence-based protocols, naviHealth's high-touch, proven care model fully supports patients from pre-acute through to the home. With naviHealth, patients can enjoy more days at home, and healthcare providers and health plans can significantly reduce costs specific to unnecessary care and readmissions. For more information about naviHealth, visit m .

                    Our Values

                    Rooted in respect

                    Guided by purpose

                    Devoted to service

                    Energized by impact

                    The above statements are intended to describe the general nature and level of work performed by colleagues assigned to this job. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications. naviHealth reserves the right to amend and change responsibilities to meet business and organizational needs as necessary.

                    naviHealth is an Equal Opportunity Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, sexual orientation, gender identity, national origin, protected veteran status, or any other protected status under applicable laws and will not be discriminated against on the basis of disability.

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                    Posting ID: 566873123Posted: 2020-08-09