Location: Orange, California US
Job Number: 1972
Position Title: Manager, Credentialing
The Manager, Credentialing will lead the credentialing activities to ensure that standards are met. The Manager, Credentialing is responsible for direct oversight of the day-to-day operations in the Credentialing Department, including overseeing all aspects of the credentialing and re-credentialing process, assisting in developing policies and procedures as well as regulatory and accreditation requirements. It is essential that the Manager, Credentialing have credentialing knowledge for the full range of provider types and privileges.
The Manager, Credentialing reports directly to the Director of Quality Management & Credentialing.
(May include but are not limited to)
- Supports the Credentialing Program
- Participates in the development and implementation of credentialing processes and procedures
- Hires, supervises, trains, reviews, and sets goals for the team and the individual staff
- Ensures the credentialing/re-credentialing processes are conducted in accordance to regulatory and accreditation requirements, as applicable.
- Serves as a resource to departmental staff and internal departments regarding credentialing activities
- Works with Credentialing Staff and/or QM Manager to prepare files and presentations for Credentialing Peer Review Committee
- Reviews workflows, procedures, and/or policies and recommend or change items to meet regulatory and accreditation requirements.
- Assists in the development and implementation of credentialing related policies and procedures.
- Identifies and conducts performance feedback and/or counseling/corrective action meetings with the assistance of Human Capital as necessary
- Assists the QM Director with budget related credentialing activities
- Prepares for regulatory and internal audits, provides additional information as requested, and develops responses or corrective action plans as required.
- Collects, monitors and analyzes credentialing data and prepares reports for submission as need to compliance, Quality Director and others as needed
- Other projects and duties as assigned
Supervises Credentialing Staff
- Certified Provider Credentialing Specialist (CPCS) or similar certification required, and 3 years credentialing experience required; or, CPCS preferred and 5 years of credentialing experience required.
- 2 years managerial or equivalent experience
- Experience in a health care delivery system, such as a health plan, medical group, or hospital preferred
- Knowledge of Regulatory and accreditation standards and guidelines- DHCS, DMHC, CMS, Joint Commission, and NCQA
- Expertise in Microsoft Office (Word, Excel, and Access)
- Knowledge of CAQH Proview and credentialing platforms such as Gemini
- Strong interpersonal skills along with strong communication and customer service skills.
- Ability to manage a fast-paced desk with the ability to prioritize and delegate appropriately.
- Must be a team player with professional demeanor, possess a good work ethic, be a problem solver, and take personal pride in their work
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to talk or hear.
- The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
- The employee frequently lifts and/or moves up to 10 pounds.
- Specific vision abilities required by this job include close vision and the ability to adjust focus.
Location City: Orange
Location State: California
Community / Marketing Title: Manager, Credentialing
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