Job Overview:
Oversees the entire process of verifying and maintaining healthcare provider credentials, ensuring compliance with state, federal, and institutional regulations by managing a team of credentialing specialists, developing policies, monitoring data accuracy, and presenting credentialing information to relevant committees, while acting as a liaison with regulatory agencies and health plans to maintain accurate provider information and proper credentialing procedures.
Qualifications:
Required:
- Bachelor's Degree in a related field
- 3 5 years of relevant healthcare experience
- Strong computer skills and skills in copiers, fax machines, etc.
- Ability to present a professional image to multiple groups/stakeholders
- Ability to form collaborative relationships
- Demonstrates effective and responsive interpersonal skills capable of gaining immediate credibility with individuals through experience, presentation, and communication skills
- Demonstrates critical and analytical skills
- Experience with effective conflict resolution skills
- Demonstrates ability to work strategically in identifying the MSO s priorities
- Exceptional communication skills verbal and written
- Experience in data base management
- Knowledgeable about the use and implementation of technology to facilitate the work of the medical staff organization.
Preferred:
- Certified Provider Credentialing Specialist (CPCS) and /or Certified Professional in Medical Services (CPMSM). Certification to be obtained within 3 years of hire.
Essential Functions:
- Lead and manage a team of credentialing specialists, assigning tasks, reviewing work, and ensuring timely completion of credentialing processes.
- Stay updated on all relevant credentialing regulations, including CAQH standards, state licensing requirements, and payer-specific guidelines to maintain compliance.
- Oversee the entire credentialing lifecycle, including initial credentialing, re-credentialing, and ongoing monitoring of provider information.
- Ensure accuracy and completeness of provider data within credentialing systems, including primary source verification and regular data audits.
- Coordinate with payers to facilitate provider enrollment processes and manage delegated credentialing agreements.
- Prepare comprehensive credentialing files for review by the credentialing committee, presenting findings and addressing any concerns.
- Implement quality control measures to monitor credentialing processes and identify areas for improvement.
- Generate reports on credentialing metrics, including turnaround times, compliance issues, and provider status updates.
- Collaborate with medical staff leadership, legal counsel, and other departments to address credentialing related issues.
- Thorough knowledge of state and federal healthcare laws, including HIPAA and credentialing standards
- Ability to review complex medical records and identify potential credentialing issues
- Effective communication with providers, payers, internal stakeholders, and regulatory agencies
- Ability to manage multiple credentialing projects simultaneously with tight deadlines
- Demonstrates Competency in the Following Areas: Analyze and implement process improvements to enhance efficiency of credentialing Conduct on-going program evaluations and audits of data integrity.
- Ensure accurate outcomes and compliant procedures to meet service goals
Coordinates with practice management, licensing agencies, insurance carriers, and other appropriate organizations to complete credentialing and re-credentialing applications - Manages staff including interviewing and selecting qualified candidates, coaching for career development, training, monitor productivity and accuracy, conduct performance evaluations, guidelines and changes, consistent application of HR policies and procedures, and guide staff to
confident decision-making. - Serve as primary resource to employees with regards to issues, interpretation and application of organization and department policies and procedures.
- Direct the output of a team of employees engaged in credentialing of providers Resolve the most complex problems related to credentialing.
- Support, participate and contribute to the development and growth of credentialing functions
- Works with various departments to ensure a smooth transition of providers when on-boarding, for new contracts and during acquisitions.
- Assumes responsibility for own personal continuing education and developmental needs; attends meetings, workshops to enrich personal knowledge, growth and management skills.
- Demonstrates the ability to be flexible, organized and function under stressful situations. Fosters good public relations for the company and the client.
Other Duties:
Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change at any time with or without notice.
Benefits and Perks:
At RWJBarnabas Health, our market-competitive Total Rewards package provides comprehensive benefits and resources to support our employees physical, emotional, social, and financial health.
- Paid Time Off (PTO)
- Medical and Prescription Drug Insurance
- Dental and Vision Insurance
- Retirement Plans
- Short & Long Term Disability
- Life & Accidental Death Insurance
- Tuition Reimbursement
- Health Care/Dependent Care Flexible Spending Accounts
- Wellness Programs
- Voluntary Benefits (e.g., Pet Insurance)
- Discounts Through our Partners such as NJ Devils, NJ PAC, Verizon, and more!
Choosing RWJBarnabas Health!
RWJBarnabas Health is the premier health care destination providing patient-centered, high-quality academic medicine in a compassionate and equitable manner, while delivering a best-in-class work experience to every member of the team. We honor and appreciate the privilege of creating and sustaining healthier communities, one person and one community at a time. As the leading academic health system in New Jersey, we advance innovative strategies in high-quality patient care, education, and research to address both the clinical and social determinants of health.
RWJBarnabas Health aims to truly make a unique impact in local communities throughout New Jersey. From vastly improving the health of local residents to creating educational and career opportunities, this combination greatly benefits the state. We understand the growing and evolving needs of residents in New Jersey whether that be enhancing the coordination for treating complex health conditions or improving community health through local programs and education.
Equal Opportunity Employer
