Credentialing Manager

Looking for a way to make an impact and help people? Join PacificSource and help our members access quality, affordable care! PacificSource is an equal opportunity employer.
All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.
Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve.
We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person’s talents and strengths.
Manage all provider credentialing, recredentialing, and document and related data management processes for PacificSource, including Site and Medical Record Survey process for new and existing providers, and NCQA or other requirements and criteria.
Collaborate with provider partners, internal customers, and other external constituents to ensure credentialing operations support key company objectives.
Supervise and provide guidance to assigned staff.
Participate in hiring process.
Train and evaluate team member performance.
Demonstrate effective leadership by developing teamwork and team support, managing change and encouraging innovation, building collaborative relationships, encouraging involvement and initiative, and developing increased vision and commitment to goals.
Essential Responsibilities: Responsible for oversight, management, development, implementation, and communication of department programs.
Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.
Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
Collaborate with Credentialing Committee leadership to facilitate provider approval processes.
Develop annual budgets.
Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
Responsible for proactively working with other departments to improve interdepartmental processes.
Utilize lean methodologies for continuous improvement.
Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
Actively participate as a key team member in Manager/Supervisor meetings.
Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.
Provide oversight of staff including Team Leads and development of appropriate processes and templates necessary for execution of the key credentialing processes, including site surveys.
Direct oversight of travel and expenses processes related to the survey process.
Monitor practitioner profiles under strict confidentiality requirements.
Continually assess and improve Credentialing team processes, including use of Cactus and data management processes with other Provider Network teams (i.
e.
Operations).
Continually be aware of, assess, and improve the credentialing team’s profile with company leaders.
Develop and implement systems and procedures to ensure program criteria compliance pursuant to standards, guidelines, and requirements of various recognized accrediting bodies.
Resolve problems and issues for both credentialing and survey analysts as they arise.
Collaborate with all other departments throughout PacificSource.
Responsible for review of any appropriate HIPAA processes including contracting and various payors.
Develop and Implement adequate programs and processes insuring a complete credentialing program that meets or exceeds requirements.
Maintain open communication with practitioners relating to required credentialing and survey processes.
Develop and maintain team training to insure up-to-date knowledge of required standards and guidelines for conduction the credentialing of practitioners that meets or exceeds organizational commitments to excellence through accreditation.
Maintain and negotiate delegated credentialing agreements included in the contracting process.
Engages in PacificSource leadership teams for positive organizational, regional, departmental and team-based cultural impacts.
Coordinate business activities in support of proper accreditations (NCQA) for PacificSource.
Supporting Responsibilities: Meet department and company performance and attendance expectations.
Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security.
Performs other duties as assigned.
Work Experience: Minimum of five years health insurance experience with at least three years credentialing experience and three years of experience managing teams in a health care environment.
Equivalent combination of education and experience may apply.
Education, Certificates, Licenses: High school or equivalent required.
Bachelor’s degree preferred.
Knowledge: Knowledge of healthcare delivery, NCQA and HIPAA are essential.
Ability to gain knowledge of PacificSource policies and procedures.
Foster attitude of cooperation and professionalism with external and internal contacts.
Ability to identify problems and work toward problem resolution independently, seeking guidance as needed.
Attention to detail; ability to handle multiple tasks and prioritize effectively.
Must show initiative in approaching projects and day-to-day work.
Attendance at meetings beyond regular business hours is required.
Must be proficient in Word, Excel, Databases and credentialing software programs.
Environment: Work inside in a general office setting with ergonomically configured equipment.
Travel is required approximately 25% of the time.
Skills: Accountable leadership, Collaboration, Communication, Data-driven & Analytical, Delegation, Listening (active), Situational Leadership, Strategic Thinking Our Values We live and breathe our values.
In fact, our culture is driven by these seven core values which guide us in how we do business: We are committed to doing the right thing.
We are one team working toward a common goal.
We are each responsible for customer service.
We practice open communication at all levels of the company to foster individual, team and company growth.
We actively participate in efforts to improve our many communities-internally and externally.
We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
We encourage creativity, innovation, and the pursuit of excellence.
Physical Requirements: Stoop and bend.
Sit and/or stand for extended periods of time while performing core job functions.
Repetitive motions to include typing, sorting and filing.
Light lifting and carrying of files and business materials.
Ability to read and comprehend both written and spoken English.
Communicate clearly and effectively.
Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change.
It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position.
Employment remains AT-WILL at all times.