Credentialing Manager - University of Rochester

GENERAL PURPOSE: Oversees departmental activities to ensure quality in conducting, maintaining, and communicating the medical and allied health professional staff credentialing, privileging, and primary source verification process. Serves as a leading resource of the department, and collaborates with others to advance the quality of practitioners and patient safety of the facility. **JOB DUTIES AND RESPONSIBILITIES:** **Credentialing and Verification Functions:** 1. Supervises the timely and accurate completion of health care professionals¿ credentialing and re-credentialing applications for internal or external assigned health care organizations. This includes the primary source verification and collection of documentation for licensing, board certifications, proof of professional liability insurance, National Practitioner. Data Bank (NPDB) and/or other sources as required based on Joint Commission and NCQA standards, hospital requirements and credentialing policies. 2. Ensures the accurate collection and documentation of annual requirements and practitioner privilege requests. 3. Responsible for ensuring that files are completed and securely submitted to the respective entities upon completion, within required timelines and in accordance with the specific contracts. 4. Sets up internal or external assigned health care organizations with NPDB CC (National Practitioner Databank Continuous Query), monitors statuses and notify hospital affiliates and clients of reports. 5. Collaborates with physicians, dentists and allied health practitioner leaders to develop and maintain a specialty specific, criteria based clinical privileging system in accordance with regulatory requirements, accreditation standards and organizational policies. **Regulatory and Compliance & Medical Staff Rules & Regulations, Policies and Procedures:** 1. Responsible for ensuring that the Medical Staff Services department is in compliance with regulatory standards, including but not limited to, The Joint Commission TJC, Center for Medicaid and Medicare Services (CMS), National Committee for Quality Assurance (NCQA), State Department of Health, Occupational Health and Safety Association (OSHA) and other regulatory agencies that govern healthcare. 2. Supervises the ongoing compliance monitoring including, and not limited to monitoring of health review requirements (OSHA), professional license, DEA, sanctions, NPDB, complaints and adverse information regarding quality of care. 3. In collaboration with the Payer Enrollment Manager, coordinates the functions related to URMFG's Delegated Credentialing/Commercial Payer Enrollment Contracts with contracted commercial payers. 4. Represents Medical Staff Office and Credentials Verification Organization (CVO) for regulatory audit/surveys by the JC, NCQA, DOH, CMS, Delegated Commercial Payers and any other regulatory agency as needed. 5. Collaborates with the UR Contracting Department and Commercial Payers regarding new and existing contracts as they relate to the delegated credentialing functions and reviews contracts for appropriateness. 6. Collaborates with the leadership team in the development and maintenance of credentialing policies to ensure the organization is compliant with regulatory standards and that all practices are current. 7. Provides education to staff pertaining to medical staff bylaws and credentialing policies and procedures. 8. Collaborates with various national and state leaders and associations and attend educational seminars and/or conferences to remain current with best practice, evolving standards, technology and service options available to the industry at large. **Oversees the Credentials Privilege Review, Committee and Board Approval Process:** 1. Supervises the departmental review and recommendation process of credentials files for membership and privileges at multiple affiliate hospitals. 2. Supervises the privileging approval process for Strong Memorial Hospital and Highland Hospital. 3. Manages the department approval process for FPPE/OPPE for Strong Memorial and Highland hospital. 4. Manages the Credentials Privilege and Review Committee Process for the approval of Medical Staff and Allied Health practitioner appointments and privileges at multiple affiliate hospitals. 5. Supervises and responsible for the weekly expedited Credentials Privilege and Review Committee, Medical Executive and Board approval process for multiple affiliate hospitals. 6. Supervises the Emergency Privilege process for hospital privileges as needed for all affiliate hospitals. **Data Management and Process Improvement Functions:** 1. Develops and maintains the electronic privileging data and criteria within the credentialing software database. 2. Responsible for maintaining data within the software system and for ensuring security is appropriate and limited to the client/hospital affiliate and the staff. 3. Develops, coordinates and monitors the quality initiative activities, including and not limited to, tracking staff performance of file processing accuracy and completion rates. 4. Responsible for ongoing review and assessment of the departmental processes and functions to identify areas in need of improvement and implement changes as needed. 5. Maintains account data to be able to provide accurate reporting on active and historical medical and allied health professional staff. 6. Collaborates with the LEAN Performance Improvement Office on various activities within the department and throughout the system as applicable. **Performance Management and Recruitment:** 1. Recruits, hires, performance manages and supervises qualified staff to accomplish departmental operations and functions. 2. Responsible for thoroughly assessing performance and processes and identifying areas of opportunity for improvement of processes and utilization of resources. 3. Develops and implements tools and policies to support knowledge management, record keeping, and internal and external communication 4. Collaborates with and assists the director with the overall management and supervision of all Medical Staff Services Department staff, which includes team building and the development and implementation of retention strategies. 5. Reviews performance measures and goals with staff regularly. Develop performance improvement plans as applicable for staff not meeting goals. **Additional responsibilities:** 1. Telehealth Activities: Coordination and oversight of the Proxy Credentialing functions and agreements associated with URMC's contracted Telehealth services. 2. Responsible for invoicing and monitoring accounts receivable for Credentials Verification Services provided to affiliates and non-affiliate clients in accordance with the contracts. 3. Assists the Director and provides oversight of the fiscal management and administrative activities for the department. 4. Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise. 5. Represents the Medical Staff Services Department for various initiatives and/or committee meeting as needed. 6. Serves as the primary back up to the MSS Department Director and other MSS Department Managers Other duties as assigned. **QUALIFICATIONS:** Bachelor's Degree required in business or healthcare related field. 5 years of experience in Medical Staff credentialing and/or payer enrollment functions required including experience with Joint Commission, CMS, and NCQA Regulations related to medical staff services and Commercial Payers Credentialing or equivalent combination of education and experience; Management experience preferred. Preferred knowledge, skills and abilities: Excellent interpersonal and communication skills with the ability to develop and maintain relationships with a variety of key stakeholders across the organization; Demonstrated success in leading through change while utilizing effective change management tools. Certified Professional Medical Services Management (CPMSM) and/or Certified Provider Credentialing Specialist (CPCS) preferred. The University of Rochester is committed to fostering, cultivating, and preserving a culture of equity, diversity, and inclusion to advance the University’s mission to Learn, Discover, Heal, Create – and Make the World Ever Better. In support of our values and those of our society, the University is committed to not discriminating on the basis of age, color, disability, ethnicity, gender identity or expression, genetic information, marital status, military/veteran status, national origin, race, religion/creed, sex, sexual orientation, citizenship status, or any other status protected by law. This commitment extends to the administration of our policies, admissions, employment, access, and recruitment of candidates from underrepresented populations, veterans, and persons with disabilities consistent with these values and government contractor Affirmative Action obligations. **How To Apply** All applicants must apply online. _EOE Minorities/Females/Protected Veterans/Disabled_ **Pay Range** Pay Range: $58,800 - $82,300 Annually _The referenced pay range represents the minimum and maximum compensation for this job. Individual annual salaries/hourly rates will be set within the job’s compensation range, and will be determined by considering factors including, but not limited to, market data, education, experience, qualifications, expertise of the individual, and internal equity considerations._ Apply for Job + Careers + Sign In + New User **Location:** Medical Faculty Group **Full/Part Time:** Full-Time **Opening:** **Schedule:**