JOB DESCRIPTION:
- Works with market leaders nationally to understand manpower plan in each market and define payor/credentialing efforts accordingly. This activity includes reviewing pre-onboard data to ensure the payors align with the Tenet agreements and 100% of volume remains intact post-onboard.
- Directs and prioritizes team efforts to ensure providers can bill and collect by the providers defined start date.
- Works with the onboarding team closely to manage changes with each project.
- Drive the data to all practices to ensure patient management on the front-end aligns with our agreements.
- Resolve patient access issues pending payor corrections/load/credentialing to ensure patients are not impacted due to administrative challenges.
- Achieve and maintain NCQA Accreditation so delegated strategy can be rolled out to all payors.
- Build and navigate sensitive payor relationships outside of managed care to resolve major issues within TPR. This includes all payors Tenet has agreements with - to include CMS and Medicare MACs and Medicaid Leadership.
- Communicate super-specialist providers onboarding to ensure the enhanced rates are tied to this portfolio by health plan.
- Collaborate with managed care to resolve loading issues and claims not paid per contract.
- Delegated credentialing agreement negotiations.
- Special projects that drive revenue from a contracting/steerage perspective and prioritize managed care efforts based on TPR market need.
- Challenge payor agenda to drive process improvement on the front and back-end - including delegation.
- Contract language interpretation and ensures alignment across physician practices.
- Manage IPA relationships.
- Resolve claims issues that flow to the credentialing worklist within the billing platform in all markets that are related to credentialing disconnects and/or education opportunities.
- Denial management for all payors including CMS (Medicare/Medicaid).
- Responsible for creating billing scenarios in the billing platform that mirror the credentialing structure for all payors.
- Root cause resolution for internal challenges that causes denials (file maintenance, RCM, Athena partners).
- Make adjustment recommendations on "dead" A/R.
- Projects either nationally or at the market level - as assigned.
- Large dollar/out of the box strategies that must be managed to completion.
- Supervises the initial and re-credentialing process for the TPR Credentialing Staff assuring credentialing accuracy and timely follow-up.
- Advises key individuals regarding credentialing issues i.e. interprets standards and regulations to assure compliance with State Board of Medical Examiners, NCQA, CMS and other regulatory agencies, identifies “red flags”, recommends solutions and/or alternatives for unusual situations credentialing applications received.
- Works with the CMO to manage the credentialing committee for TPR to make internal credentialing decisions on the entire portfolio for our delegated partners and ensures there is consistently a diverse specialty mix membership.
- Ensures Policies and Procedures are maintained with latest regulatory updates at an NCQA, State Mandate and CMS level at all times.
- Responsible for communicating with our health plan contacts on a routine basis to ensure ongoing and accurate participation status for our employed physicians at all sites in which the physician is rendering services. This includes initial credentialing/re-credentialing and requests for additional sites.
- Maintains an accurate and up-to-date credentialing database.
- Overseeing the overall operations and supervision of the Credentialing Department, including routine credentialing activity and management of department staff.
- Includes employee selection, counseling, evaluations, disciplinary action, and terminations; development/revision of credentialing policies and procedures, credentialing job descriptions, required in-service education, etc.
- Ensures staff meet productivity standards set for the department.
REQUIREMENTS
- High school diploma/GED is required.
- Bachelor’s degree in healthcare management, public health, accounting, finance, business, social or behavioral sciences preferred or equivalent work experience.
- 7-10 years of previous managed care leadership experience and/or 5+ years’ experience in a credentialing leadership role.
- Must have the ability to travel up to 25% nationally. Selected candidate will be required to pass a Motor Vehicle Record check.
- Knowledge of primary source verification, provider enrollment, and NCQA credentialing requirements.
- Excellent analytical abilities and communication skills including the ability to communicate with stakeholders and decision-makers across the spectrum of the organization, from senior business leaders to subordinates.
- Experience in progressive health care management with emphasis in health plan/provider contracting and physician group management/contracting.
- In-depth knowledge of health plan and governmental payer credentialing, enrollment, and requirements.
- Ability to work within a deadline-intense environment.
- Demonstrated problem-solving and customer service skills.
Tenet Healthcare complies with federal, state, and/or local laws regarding mandatory vaccination of its workforce. If you are offered this position and must be vaccinated under any applicable law, you will be required to show proof of full vaccination or obtain an approval of a religious or medical exemption prior to your start date. If you receive an exemption from the vaccination requirement, you will be required to submit to regular testing in accordance with the law.
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Employment practices will not be influenced or affected by an applicant’s or employee’s race, color, religion, sex (including pregnancy), national origin, age, disability, genetic information, sexual orientation, gender identity or expression, veteran status or any other legally protected status. Tenet will make reasonable accommodations for qualified individuals with disabilities unless doing so would result in an undue hardship.
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