Job Description

The Credentialing Director will work with internal experts in provider credentialing and service operations to continue building a US and Philippines-based credentialing network for Tenet and United Surgical Partners International. In addition to overseeing the overall operations and supervision of the credentialing departments, he or she will interface with our colleagues in legal, revenue cycle, compliance, regulatory accreditation, and managed care. Responsibilities will include oversight and efficient usage of all credentialing systems and databases, creation, and submission of all credentialing applications for the physicians and allied health professions both on paper and on-line applications with CAQH, creating and maintaining delegated credentialing agreements, performing root cause denial analysis, and make accounts receivable write-off recommendations.

• Defines payor credentialing strategy nationally
  • Work with market leaders nationally to understand manpower plan in each market and define payor credentialing efforts accordingly. This activity includes reviewing pre-onboard data to ensure the payors align with the Tenet agreements and 100% of volume remains intact post-onboard.
  • Direct and prioritize team efforts to ensure providers can bill and collect by the providers defined start date.
  • Work with the onboarding team closely to manage changes with each project.
  • Drive the data to all practices to ensure patient management on the front-end aligns with our agreements.
  • Resolve patient access issues pending payor corrections/load/credentialing to ensure patients are not impacted due to administrative challenges.
  • Achieve and maintain NCQA Accreditation so delegated strategy can be rolled out to all payors.
• Managed Care liaison
  • Build and navigate sensitive payor relationships outside of managed care to resolve major issues within TPR. This includes all payors with which Tenet has agreements
  • Communicate super-specialist providers onboarding to ensure the enhanced rates are tied to this portfolio by health plan.
  • Collaborate with managed care to resolve loading issues and claims not paid per contract.
  • Maintain and further develop delegated credentialing agreements
  • Challenge payor agenda to drive process improvement on the front and back-end - including delegation.
  • Resource for contract language interpretation.
  • Manage IPA relationships.
• Revenue Cycle - Credentialing
  • Resolve claims issues that flow to the credentialing worklist within the billing platform in all markets.
  • Assist with denial management for all payors including CMS (Medicare/Medicaid).
  • Responsible for creating billing scenarios in the billing platform that mirror the credentialing structure for all payors.
  • Root cause resolution for internal challenges that causes denials (file maintenance, RCM, Athena partners)
  • Make adjustment recommendations on aged and deemed uncollectable A/R.
• Communicate with our health plan contacts on a routine basis to ensure ongoing and accurate participation status for our employed physicians at all sites in which the physician is rendering services. This includes initial credentialing/re-credentialing and requests for additional sites.
• Maintain internal credentialing database and excel spreadsheets on a routine basis.
• Create and monitor Productivity Standard Reports to ensure staff are meeting the standards set for the department.
• Oversee the overall operations and supervision of the Credentialing Department, this includes routine credentialing activity and management of department staff.
  • Includes employee selection, evaluation, disciplinary action, and terminations; development/revision of credentialing policies and procedures, credentialing job descriptions and required in-service education.
• Minimal travel. Selected candidate will be required to pass a Motor Vehicle Records check.

Education: Bachelor’s degree and/or equivalent work history required. MBA preferred.

Experience:

• Ten years of experience in a service operations managing proximate and distal workforce.
• Five years supervisory experience with excellent management skills.
• Must be able to work in a team-oriented environment.
• Excellent written and oral communication skills.
• Working knowledge of Microsoft Word and Excel.
• Excellent time management and organizational skills.
• Proficiency in all applicable software / databases utilized.
• Understanding of HIPAA, Joint Commission, NCQA, CMS standards and patient confidentiality regulations.
• Working knowledge of automating tools, including RPA, ML, and AI.