Credentialing Service Manager - Physician Partners - 1827 Woodman Center Drive - Kettering - FT - Kettering Health

Kettering Health is a not-for-profit system of 13 medical centers and more than 120 outpatient facilities serving southwest Ohio. We are committed to transforming the health care experience with high-quality care for every stage of life. Our service-oriented mission is in action every day, whether it’s by providing care in our facilities, training the next generation of health care professionals, or serving others through international outreach.

Responsibilities & Requirements:

Oversee the credentialing and enrollment process for healthcare providers seeking participation in the Kettering Health Physician Partners insurance networks or plans. You will ensure that providers meet the credentialing requirements set forth by the National Committee for Quality Assurance (NCQA) and other regulatory bodies, oversee the delegated credentialing process, and maintain compliance with accreditation standards. This role requires expertise in NCQA delegated credentialing requirements, strong leadership skills, attention to detail, and the ability to effectively collaborate with internal and external stakeholders. This position is also responsible for provider relationship management, annual contract open enrollment, claims management and provider data management.

Performs other duties as assigned.

Essential Functions:

NCQA Delegated Credentialing Oversight:

· Develop and implement policies, procedures, and workflows for NCQA delegated credentialing in accordance with NCQA standards and guidelines.

· Ensure that the delegated credentialing process meets NCQA requirements for credentialing, recredentialing, and ongoing monitoring of providers.

· Serves as primary liaison with delegated entities, such as physician groups or Kettering Health central credentialing office, to facilitate the credentialing process and ensure compliance with NCQA standards.

· Monitor delegated entities' performance and adherence to NCQA requirements through regular audits and quality assessments.

· Manages NCQA Accreditation Surveys and Annual Payor Audits

Credentialing and Enrollment Process Management:

· Manage the credentialing and enrollment process for healthcare providers seeking participation in payor networks or plans.

· Review provider applications and documentation to ensure compliance with NCQA delegated credentialing standards and payor requirements.

· Coordinate the verification of provider credentials, licenses, certifications, and other qualifications through primary sources.

· Conduct background checks, review malpractice history, and assess provider competence as part of the credentialing process.

· Oversee the enrollment of approved providers in payor networks, including contract negotiations and execution of participation agreements.

· Manage the enrollment process for approved providers to join payor networks or plans.

· Ensure timely and accurate completion of enrollment forms and documentation.

· Monitor enrollment status and address any issues or discrepancies that arise during the process.

Quality Assurance and Compliance:

· Ensure that credentialing and enrollment activities adhere to NCQA standards, regulatory requirements, and accreditation standards.

· Conduct internal audits and quality assessments to monitor the effectiveness and accuracy of the credentialing and enrollment process.

· Implement corrective actions and process improvements to address deficiencies and enhance compliance with NCQA requirements.

· Stay abreast of changes in NCQA standards, healthcare regulations, and industry best practices related to delegated credentialing and enrollment.

· Participate in quality improvement initiatives to enhance the efficiency and effectiveness of the credentialing and enrollment process.

· Stay informed about changes in healthcare regulations, accreditation standards, and payor requirements that may impact credentialing and enrollment practices.

· Implement corrective actions and process improvements to address compliance deficiencies and mitigate risks.

Provider Relationship Management:

· Serve as the primary point of contact for providers regarding credentialing, enrollment, and NCQA delegated credentialing inquiries.

· Establish and maintain positive relationships with delegated entities, payor representatives, and internal stakeholders involved in the credentialing process.

· Provide guidance and support to providers on NCQA delegated credentialing requirements, application procedures, and ongoing compliance.

· Serve as the primary point of contact for providers regarding credentialing and enrollment inquiries.

· Provide guidance and support to providers on credentialing requirements, application procedures, and ongoing compliance.

· Manages annual contracts open enrollment

· Manages all claims issues that practices experience and works on resolution with the payors

Provider Data Management and Reporting:

· Maintain accurate and up-to-date provider information in the credentialing and enrollment database.

· Generate reports and metrics to track the status of credentialing and enrollment activities, identify trends, and measure performance against established benchmarks.

· Ensure compliance with data privacy and security regulations when handling sensitive provider information.

Required Qualifications:

· Bachelor's degree in healthcare administration, business administration, or a related field (Master's degree preferred).

· Minimum of 5 years of experience in healthcare credentialing and enrollment, with at least 2 years of experience specifically in NCQA delegated credentialing-preferred in a medical staff or managed care office or credentialing verification organization.

· In-depth knowledge of NCQA delegated credentialing standards, requirements, and processes.

· Strong understanding of healthcare regulations, accreditation standards, and payor requirements related to credentialing and enrollment.

· Excellent leadership, communication, and interpersonal skills.

· Proficiency in using credentialing and enrollment software systems.

· Certification in healthcare credentialing -Certified Professional in Medical Services Management (CPMSM), or Certified Provider Credentialing Specialist (CPCS) from the national Association of Medical Staff Services (NAMSS) is required.

· Proficiency in using credentialing and enrollment software systems.

Required skills include but are not limited to the following:

· Basic computer skills, data entry experience and accurate typing of 40 - 50 words per minutes required.

· Proficiency in the use of Microsoft Office, Excel and Access preferred.

· Proficiency in MSOW or other credentialing software preferred.

· Must be well organized for prioritization of responsibilities; detail oriented; independent judgment skills.