Status: Regular Full-time, FLSA Exempt
Location: Tacoma, WA
Reports to: Chief Operations Officer
Under minimal supervision oversees credentialing/privileging program to assure credentialing processes are in compliance with professional standards and state and federal regulatory requirements; health plan delegation for credentialing is maintained, and corporate growth initiatives are supported. This individual and team play a key role in linking operations and systems to ensure these functions are in sync with corporate growth initiatives. This position supports the Credentialing Committee and Medical Director in assuring that the credentialing process meets company and payer standards.
ESSENTIAL DUTIES & RESPONSIBILITIES
The duties listed below are intended only as illustrations of the various types of work that may be performed. The omission of specific statements of duties does not exclude them from the position if the work is similar, related or a logical assignment.
40% Credentialing and Privileging
- 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) and the Washington Department of Health (list is not all-inclusive).
- 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.
- Assures credentialing practices are within the scope and goals of the Approved Quality Programs set forth by The OputmCare Network (OCN).
- Oversees and supports the day to day operations of OCN 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 tier 3 and 4 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 work load 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.
KNOWLEDGE, SKILLS AND ABILITIES
Knowledge: Regulatory requirements of CMS, National Committee for Quality Assurance and the Utilization Review Accreditation Commission. Credentialing and Privileging best practices.
Skills: Proficient in keyboard and computer skills including MS Word, Excel and credentialing software
Abilities: Ability to work independently and interact effectively in multi-cultural professional environment. Attention to detail, and accuracy.
Education: Bachelor's degree in Business or related field, or equivalent experience.
Experience: Minimum of three to five years of supervisory experience. Minimum of five years in a Credentialing/Medical Staff environment.
Certificate/License: Certified Professional Medical Services Management (CPMSM) or Certified Provider Credentialing Specialist (CPCS) certification, required
Office equipment, computer, personal vehicle
MENTAL & PHYSICAL DEMANDS/WORKING CONDITIONS
- Mental Effort: Must be able to work effectively as a member of NPN team; work is detailed and complex with multiple competing priorities, deadlines and internal and external customers
- Physical Requirements: Work is primarily in office environment requiring ability to see and hear and communicate as well as operate personal motor vehicle
- Working Conditions: Work is performed both in an office setting and at clinic locations; noise level may be moderate or loud on occasion; work may be required outside normal business hours
The job description does not constitute a written or implied contract of employment. NPN reserves the right to revise or change job duties and responsibilities as the need arises