Manager, Provider Credentialing, Data & Reporting

Salary Range: $130,622 - $202,465
The expected pay range is based on many factors, such as experience, education, and the market. The range is subject to change.

FLSA Status:Exempt
Department:Provider Network Management
Reports To:Director of Provider Network Management

The Manager, Provider Credentialing, Data and Reporting manages the end-to-end credentialing process, and all aspects of provider data including data entry, maintenance and reporting, provider databases and management of the personnel responsible for these activities.

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.

1. Manage all aspects of provider credentialing including initial and re-credentialing processes in accordance with federal, state, and NCQA guidance.
2. Manage the Credentialing Peer Review Committee and support preparation of documents for committee meetings.
3. Oversee the relationship with the Credentials Verification Organization (CVO) to ensure timely, accurate and complete submission/return of files and information exchange for all SCFHP directly contracted/credentialed providers.
4. In coordination with IT, ensure appropriate background screening of all SCHHP contracted providers.
5. Oversee the development of the Access and Availability program and management of the Access and Availability workgroup, and the Annual Network Certification (ANC) process, including coordination between team members to identify appropriate interventions and actions necessary to improve access to timely care for members.
6. Manage relationships with delegates to develop processes to exchange accurate provider rosters in a timely manner, conduct data validation of information provided, implement maintenance processes of reports and electronic data files received and provide feedback regarding discrepancies.
7. Develop processes to ensure the review and validation of all provider information including demographics, credentialing, and accessibility data for inclusion in all health plan provider directories and in electronic format for use on the Health Plan website, web portals and to meet all regulatory reporting requirements.
8. Manage and facilitate the reporting needs for all regulatory compliance network submissions required by CMS, NCQA, DHCS, and DMHC of provider data regarding access and availability, network certifications, and directories.
9. Provide leadership to ensure provider data and system configuration meets regulatory and compliance standards across all internal and external partners' reporting and operational requirements.
10. Ensure primary care and specialist provider terminations are processed timely and member panel reassignment and notification processes are completed.
11. Provide direction for the roster reconciliation and attestation process for all provider data in accordance with SB137.
12. Work with other Health Plan departments and serve on internal committees and project teams as needed.
13. Provide status updates, progress reports, and performance dashboards for the provider database and credential teams to the Director of Provider Network Management and other Health Plan Management staff. Lead and act as a subject matter expert, in projects related to provider data during core system conversions or upgrades, ensure project documents are complete, current and retained appropriately.
14. Develop policies, procedures, and relevant work aids related to credentialing, provider database functions and provider reporting for the department. Conduct internal quality verifications to ensure compliance with established policies and procedures to credentialing, provider database and reporting, and applicable regulatory reports.
15. Perform any other related duties as required or assigned.

Carries out supervisory/management responsibilities in accordance with the organization's policies, procedures, applicable regulations and laws. Responsibilities include:

1. Manage the provider credentialing, provider database, provider maintenance, and access and availability teams in regards to work priorities, projects, reports, and maintenance of the system(s), including training, promotion, enforcement and auditing of internal procedures and controls and problems; motivates employees to achieve peak productivity and performance. Monitor work schedules and time off requests to ensure that adequate coverage is available for internal staff during regular business hours.
2. Recruit, interview, and hire.
3. Develop a high performing department culture and staff. Set the standard for staff/peers and motivate employees to maximize organizational goals and objectives.
4. Effectively assimilate, train and mentor staff and (when appropriate), cross train existing staff and initiate retraining. Coach to help increase skills, knowledge and (if applicable) improve performance.
5. Set goals and plan, assign, and direct work consistent with said goals. Respond to employees' needs, ensure they have the necessary resources to do their work.
6. Appraise performance, reward and discipline employees, address complaints and resolve issues. Provide regular and effective feedback to employees and complete timely and objective performance reviews.

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.

1. Bachelor's Degree in Health Administration, Computer Science, Business Administration, or related field; or equivalent experience, training, or coursework. (R)
2. Minimum five years of experience in IT, payer relations and/or credentialing with a health plan, managed care organization, or healthcare provider. (R)
3. Strong understanding of relational databases. (R)
4. Understanding of the healthcare business related to claims, provider contracts, and credentialing specifically MediCal and MediCare. (R)
5. Working knowledge and the ability to efficiently operate all applicable computer software including applications such as Outlook, Word, Excel and the ability to communicate business needs in order to define systems and reporting requirements. (R)
6. Excellent communication skills including the ability to express oneself clearly and concisely when interacting with SCFHP internal and external stakeholders over the telephone, in person or in writing. (R)
7. Ability to problem solve, think critically and present ideas/proposals for action. (R)
8. Ability to work collaboratively with others and take ownership of one's job functions. (R)
9. Ability to document business changes, provide training to staff, and follow up on staff progress. (R)
10. Demonstrated experience in project management and business analysis. (R)
11. Leadership experience and ability to manage staff. (R)
12. Strong understanding of contracts, payment methodologies and claims system configuration. (R)
13. Ability to manage various teams and projects to drive results and achieve organizational objectives. (R)
14. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support department operations as dictated by business needs. (R)
15. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
16. Ability to maintain confidentiality. (R)
17. Ability to comply with all SCFHP policies and procedures. (R)
18. Ability to perform the job safely with respect to others, to property and to individual safety. (R)
19. Maintenance of a valid California driver's license and acceptable driving record, in order to drive to and from off-site meetings or events, or the ability to use other means of transportation to attend off-site meetings or events. (R)

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:

1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 15 pounds; (R)
3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment (R)
5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
6. Reasoning Requirements: ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)

General office conditions. May be exposed to moderate noise levels.

EOE