Manager, Provider Credentialing, Data & Reporting

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

GENERAL DESCRIPTION OF POSITION

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.

ESSENTIAL DUTIES AND RESPONSIBILITIES

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.

SUPERVISORY/MANAGEMENT RESPONSIBILITIES 

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