Credentialing Lead (Hybrid - Troy, MI) - Health Alliance Plan
GENERAL SUMMARY:
Under minimal supervision, responsible for identifying and maintaining up-to-date knowledge of NCQA, CMS standards & DIFS requirements as they relate to the credentialing function, as well as HAP & HAP Midwest Health Plan credentialing departmental policies and procedures. Assess organizational/ancillary behavioral medicine facilities application before contracting and at least every three years thereafter for behavioral medicine facilities Provide functional oversight of credentialing staff.
PRINCIPAL DUTIES AND RESPONSIBILITIES:
- Educate and train credentialing staff to ensure compliance with the regulatory and accreditation standards as well as HAP & HAP Midwest Credentialing departmental policies and procedures.
- Responsible for ensuring that the credentialing policies, procedures, and processes within the HAP and HAP Midwest Health Plan credentialing department conform to current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
- Ensure that entities which HAP and HAP Midwest Health Plan has signed delegation agreements are in compliance current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
- Advise the Manager of Credentialing about any standards changes substantial enough to require the installation of new procedures/staff training.
- Review delegated credentialing audits tools for compliance
- Assess issues that are identified from annual delegated audits. Analyze identified issues and implement resolution in a timely manner and in accordance with regulatory standards.
- Review and evaluate organizational/ancillary behavioral medicine facilities
- Confirms that the organizational/ancillary provider is in good standing with state and federal regulatory bodies.
- Confirms that the organizational/ancillary provider has been reviewed and approved by an accrediting body.
- Request onsite quality assessment if the organizational/ancillary provider is not accredited.
- Serves as a process expert to assist to ensure compliance with current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
- Prepare and coordinate documents for NCQA, CMS & DIFS audits
- Oversees the delegates credentialing/re-credentialing work responsibilities ensuring that there is accurate and timely credentialing data.
- Oversees the Physician Analysts II activities regarding delegation.
- In the absence of the Credentialing Manager assumes responsibilities for coordinating activities of the Credentialing Department.
- Assist in ensuring that the Department goals and standards are met.
- Perform other related duties as assigned.
EXPERIENCE / EDUCATION REQUIRED:
- Associate's degree is required OR four (4) years of related experience in lieu of degree. Bachelor's degree preferred.
- Minimum of five (5) years of experience in health care industry, managed care setting in credentialing and re-credentialing, processes; credentialing database and associated activities.
- Minimum of one (1) year experience with the application of NCQA standards and oversight of credentialing delegation.
- At least one (1) year experience in the use of physician credentialing database (e.g., Cactus and other software packages (e.g. Word, Excel, PowerPoint, Access or similar database).
- Minimum of five (5) years of experience in physician credentialing preferred.
- Knowledge of credentialing software.
- Knowledge of NCQA,CMS Standards& DIFs requirements.
- Ability to work under minimal supervision.
- Ability to perform detail work efficiently and with a high degree of accuracy.
- Excellent problem-solving skills.
- Highly organized.
- Ability to initiate and coordinate multiple projects simultaneously.
- Excellent verbal communication skills.
- Ability to interpret information and make judgment quickly.
- Ability to interact professionally with practitioners and other external customers.
- Strong quantitative and analytical skills.
- Computer proficient in Microsoft Office including; Word and Excel.
- Knowledge of the principles and practices of credentialing is highly desirable.
- Knowledge consistent knowledge of Department policies and processes.
CERTIFICATIONS/LICENSURES:
- Certification as CPCS (Certified Provider Credentialing Specialist) or CMSC (Certified Medical Staff Coordinator) preferred.
Overview
HAP is a Michigan-based, nonprofit health plan that provides health coverage to individuals, Â Â Â Â Â companies and organizations. A subsidiary of Henry Ford Health System, we partner with doctors, employers and community groups to enhance the overall health and well-being of the lives we touch. With more than 1,100 dedicated and passionate employees, our goal is to make health care easy for our members.
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Under the leadership of President and CEO Robert G. Riney, Henry Ford Health is a
$6 billion integrated health system comprised of six hospitals, a health plan, and 250+ sites
including medical centers, walk-in and urgent care clinics, pharmacy, eye care facilities and
other healthcare retail. Established in 1915 by auto industry pioneer Henry Ford, the health system
now has 32,000 employees and remains home to the 1,900-member Henry Ford Medical Group, one
of the nation’s oldest physician groups. An additional 2,200 physicians are also affiliated with the
health system through the Henry Ford Physician Network. Henry Ford is also one of the region’s Â
major academic medical centers, receiving between $90-$100 million in annual research funding and
remaining Michigan’s fourth largest NIH-funded institution. Also an active participant in medical
education and training, the health system has trained nearly 40% of physicians currently practicing
in the state and also provides education and training for other health professionals including nurses,
pharmacists, radiology and respiratory technicians. visit HenryFord.com.
Benefits
Whether it's offering a new medical option, helping you make healthier lifestyle choices or
making the employee enrollment selection experience easier, it's all about choice. Â Henry
Ford Health System has a new approach for its employee benefits program - My Choice
Rewards. Â My Choice Rewards is a program as diverse as the people it serves. Â There are
dozens of options for all of our employees including compensation, benefits, work/life balance
and learning - options that enhance your career and add value to your personal life. Â As an
employee you are provided access to Retirement Programs, an Employee Assistance Program
(Henry Ford Enhanced), Tuition Reimbursement, Paid Time Off, Employee Health and Wellness
and access to day care services at Bright Horizons Midtown Detroit, and a whole host of other
benefits and services. Employee's classified as contingent status are not eligible for benefits
Equal Employment Opportunity/Affirmative Action Employer
Equal Employment Opportunity / Affirmative Action Employer Henry Ford Health System is
committed to the hiring, advancement and fair treatment of all individuals without regard to
race, color, creed, religion, age, sex, national origin, disability, veteran status, size, height,
weight, marital status, family status, gender identity, sexual orientation, and genetic information,
or any other protected status in accordance with applicable federal and state laws.