Director of Credentialing Full Time
From our Dallas corporate headquarters to our clinics and worksite locations, Concentra colleagues remain focused on our driving purpose: to provide superb patient and employer experience by delivering the highest quality healthcare in an efficient, affordable, caring manner. We do this by putting all customers (internal and external) first and by displaying:
- A healing focus
- A selfless heart
- A tireless resolve
Primary responsibilities include assuring Concentra’s Credentialing Plan and processes meets the needs of our clients, payers, the market, state regulations and NCQA, Medicare/Medicaid, URAC, and/or Joint Commission credentialing standards. This includes, but is not limited to, creating and/or assisting with the development and/or implementation of supporting policies and procedures and workflows; managing and monitoring the overall Credentialing Plan, the on-going evaluation of the effectiveness of processes and procedures to support the plan; ensuring Concentra is in compliance with state regulatory, NCQA, URAC, Medicare/Medicaid, and/or Joint Commission credentialing requirements, as applicable; legislative credentialing laws; and accrediting body requirements. Management of the Credentialing process will include, but is not limited to, directing all activities associated with the credentialing and/or re-credentialing process for all clinicians and facilities in accordance with the applicable state regulations, NCQA, Medicare/Medicaid, URAC, and/or Joint Commission Standards, and all Concentra policies, procedures and practices.
The Director of Credentialing works independently but reports to the Vice President, Group Health and Managed Care Contracting, and coordinates and collaborates with Concentra business leaders and colleagues on day-to-day operations and is the subject matter expert for credentialing processes.
Major Duties and Responsibilities
- Establishes and implements strategic goals to align with department and corporate goals and objectives
- Manage and monitor the overall credentialing plan, operations and needs for compliance. Make any necessary changes.
- Develop, implement, and maintain all Credentialing activities for Concentra centers, onsites/worksites, Community-Based Outpatient Centers (CBOCs), MedicalReview Stream by Concentra, and any other credentialing needs that arise.
- Manages credentialing budget and staffing needs
- Partner with multi-functional team of business leaders on day-to-day Concentra operations.
- Maintain knowledge of all state regulatory and accrediting body standards and maintain compliance.
- Maintain knowledge of market driven and client requirements to ensure Concentra is meeting these requirements.
- Lead staff in developing, implementing and coordinating the on-going activities of all Committees (i.e., Credentialing and Appeal Committees)
- Oversee and/or manage Delegated Agreements and all audit and reporting needs associated with each.
- Participate in client, state and/or regulatory body interviews/presentations in discussions pertaining to credentialing.
- Oversee and/or manage ongoing monitoring activities: OIG Sweep (Office of Inspector General) for Medicare/Medicaid sanctions; clinician licensure renewal; Medicare Opt Out; and monthly state licensure sanctions/actions.
- Provide on-going opportunity and challenge for staff development.
- Oversee and/or manage the credentialing committee process and meetings to assure committee members have necessary information, explain questionable information contained in file and act as overall resource for general credentialing processes.
- Conduct regular meetings with direct reports and credentialing team and ensure that they are well informed of company goals and objectives, set priorities and discuss progress towards goals.
Develop mechanisms for regular on-going feedback on areas of development and/or accomplishments.
Number people supervised: 10
- Direct management experience in credentialing required.
- Professional Medical Services Management Certification (CPMSM) and/or Professional Credentialing Specialist Certification (CPCS) required or able to obtain certification within one year. Bachelor's degree (BA or BS) from four year college or university
- Minimum of 5 – 7+ years credentialing experience with at least 3 years of management/supervisory experience required. Knowledge of credentialing software (IntelliCred) preferred.
- Working knowledge of NCQA and URAC Credentialing Standards
- Ability to work independently within guidelines and company policies
- Ability to manage open projects to the end with successful follow-up
- Ability to supervise, train, and transfer job knowledge to colleagues
- Working knowledge of credentialing processes and procedures and systems.
- Working knowledge of computer software applications to include Word, Excel, Power Point, Outlook and ability to utilize proprietary Concentra software programs
- Working knowledge of credentialing organizations such as NCQA and URAC
- Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, government regulations, standardized instructions, short correspondence, and memos.
- Demonstrated excellent communication skills, both written and oral, with varying levels of colleagues, management, clients and customers
- Ability to speak effectively before groups of customers or employees of organization
- Ability to effectively present information in one-on-one situations to other employees, providers and clients.
- Must have a demonstrated understanding of credentialing as defined by legislative/regulatory or state bodies
- Must have ability to work in fast paced environment
- Must be very detail- oriented
- Must be able to make independent decisions
- Must be able to review and make necessary revisions in credentialing delegation agreements with external payer partners.
Working conditions/physical demands
- Office environment
- Fast paced environment/deadline driven
- 85+% computer terminal usage- specific vision abilities including close vision.
- 401(k) with Employer Match
- Medical/Vision/Prescription/Dental Plans
- Life Insurance/Disability
- Paid Time Off/Holidays
- Colleague Referral Bonus Program
This job requires access to confidential and sensitive information, requiring ongoing discretion and secure information management.
Concentra is an Equal Opportunity Employer, including disability/veterans