At Virginia Garcia Memorial Health Center, we welcome diversity; we encourage, uplift, and are honored to serve people who have been historically underrepresented and underserved. Our mission is to provide high-quality, culturally appropriate healthcare to low-income residents of Washington and Yamhill Counties, with a special emphasis on seasonal and migrant farm workers and others with barriers to receiving healthcare. We strive to provide an inclusive environment that welcomes and values the diversity of the people we employ and serve.
If you are unsure whether you meet all of the required qualifications for this role but are interested and passionate about this potential position, we encourage you to apply.
Job Summary: The Credentialing Manager (CM) is responsible for overseeing the Credentialing Department and supervising Credentialing staff. The CM develops and implements policies and procedures, and audits and monitors workflows and processes to ensure regulatory compliance and improve efficiency. The CM will develop or update and monitor Key Performance Indicators (KPI's), targets, and goals. The CM works collaboratively with the Billing Department in credentialing of providers for all commercial insurers and Medicare/Medicaid enrollment. The CM will take the lead in department meetings and will represent the department in cross-disciplinary team meetings. Will work closely with the Chief Operations officer on special projects.
Essential Duties and Responsibilities:
• Function as primary credentialing contact to all internal and third-party credentialing entities such as health plans, OCHIN, HRSA; develops and maintains positive working relationships.
• Manage department budget, spending, and planning.
• Determine software and vendor needs.
• Determine and ensure necessary staffing level is met.
• Develop processes, instruction sheets and training materials for the department.
• Perform credentialing, privileging, re-credentialing, and re-privileging of Licensed Independent Practitioners and other licensed or certified staff.
o Ensure completion of verifications of license, registration, certification, education, training, insurance, affiliations and experience at initial appointment and reappointment in accordance with VGMHC policies and federal regulations.
o Ensure that the Board of Directors receives pertinent credentialing and privileging information to allow them to grant or deny credentialing and privileging.
o Ensure the credentialing process for commercial insurers and Medicare/Medicaid enrollment and reassignment of benefits is performed in an accurate and timely manner.
• Maintain confidential credentialing files and provider database ensuring completeness, accuracy, and confidentiality.
• Communicate with the Medical and Dental Directors, Provider Recruiter, providers, and Billing Department regarding credentialing and privileging. Coordinate with outside organizations and community stakeholders to ensure positive and mutually beneficial relationships.
• Maintain open communication with the provider staff, Medical Directors, and Administration to identify and work to solve problems as they arise. Bring problems to the attention of Medical Directors and/or Quality Assurance Manager as they arise.
• Provide on-site consultations across Virginia Garcia (VG) with regards to credentialing practices and services; prepare and conduct credentialing orientations and provide updates as appropriate on new policies and procedures, new plan participation, etc.
• Coordinate ad hoc Credentialing Committee meetings.
• Remain well informed of current credentialing and privileging rules and requirements and ensure compliance with those rules and regulations.
• Prepares for and coordinates credentialing audits in compliance with the managed care delegated credentialing contracts, HRSA and other state and federal agencies as appropriate.
• Coordinates the management of the expirables process to ensure all contracted provider licenses and certificates remain current, and appropriate notification is provided prior to expiration.
• Oversee day-to-day credentialing and privileging operations ensuring adherence to policies and procedures.
• Serve as primary escalation point for internal business partners, credentialing specialists, providers, and clients in the resolution of issues.
• Identify creative solutions to complex situations and operational problems to improve efficiency and engagement.
• Manage credentialing requests and action items (tasks) as needed to support team capacity.
• Supervise Credentialing personnel, which includes work allocation, training, promotion, enforcement and auditing of internal procedures and controls, and problem resolution; evaluates performance and makes recommendations for personnel actions; motivates employees to achieve peak productivity and performance.
• Support and guide Credentialing Specialists to develop their skills and capabilities.
• Work closely with Chief Operations Officer on special projects.
• Perform other duties as assigned.
HIPAA Requirements:
The Credentialing Manager may have access to PHI in the course of carrying out their duties, applying the minimum necessary standard of HIPAA, the designated record sets to which this employee may have access include: all sections of the medical record, patient demographic information in the practice management system, and incoming records, reports, results, consultations, etc. The Credentialing Manager will read the content of these records only to the extent needed to accomplish the assigned task.
Knowledge, Skills and Abilities:
• Strong organizational skills to work independently and to prioritize a heavy workload under the pressure of competing assignments.
• Strong written and verbal communication skills.
• Excellent interpersonal skills to work cooperatively with people at all levels in the organization.
• Ability to respond flexibly and positively in all circumstances, and to work calmly under pressure.
• Excellent problem-solving skills.
• Attention to detail with a high degree of accuracy and a focus on process.
• Ability to exercise good judgment and discretion, especially with regards to sensitive or confidential personnel and organizational matters.
• Database management skills
• Skill in developing policy and procedure documentation
• Knowledge of related accreditation and certification requirements.
• Knowledge of medical credentialing and privileging procedures and standards.
• Knowledge of medical staff policies, regulations, and the legal environment within which they operate.
• Proficiency with Microsoft Office applications (Word, Excel, PowerPoint, Outlook).
• Strong commitment to working with staff from a wide range of ethnic, economic, cultural, and social backgrounds.
Education and Experience:
• Bachelor's degree required.
• 5 years of management experience
• 5 years of credentialing experience
• Credentialing Certification through a VG-approved organization is preferred. Certification is required within 3 years from the start date of this position. Extension of this requirement may be granted at the sole discretion of the COO.
Behavioral Competencies:
Accountability: Role model VG's mission, vision, and shared values
Customer-Focus: Listen to the voice of the customer and strive to delight them by exceeding their expectations
Teamwork: If someone needs help, help them
Initiative: Be innovative, apply fresh ideas, and continuously improve how you do your work
Confidentiality: Maintain strict confidentiality and respect the privacy of others
Ethical: Demonstrate integrity, honesty, and stewardship in all encounters at work
Respect: Demonstrate consideration and appreciation for co-workers and patients
Communication: Demonstrate the ability to convey thoughts and ideas as well as understand perspective of others
Physical Requirements: Percentage of time spent
• Standing: 10%
• Walking: 15%
• Sitting: 70%
• Reaching/stooping/bending: 5%
• Computer usage: up to 85%
Working Environment/Physical Hazards:
• Work in a well-lighted, ventilated professional office environment
Routinely use office equipment, not limited to:
• Computer ' data entry and word processing
• Telephone, fax, copier, scanner
Immunization: Staff members must meet immunization requirements as stated in VGMHC's immunization policy and state and federal guidelines.
Job descriptions represent a general outline of the essential and major job duties, functions and qualifications required. They cannot be all-inclusive and comprehensive due to the dynamic nature of work performed to accomplish VGMHC's Mission.
VGMHC is an Equal Opportunity Employer. No person is unlawfully excluded from consideration for employment because of race, color, religious creed, national origin, ancestry, sex, age, veteran status, marital status, or physical challenges. The policy applies not only to recruitment and hiring practices, but also includes affirmative action in placement, promotion, transfer, rate of pay and termination.