Director, Health Plan Enterprise Credentialing

City/State

Virginia Beach, TX

Overview

Work Shift

First (Days) (United States of America)

Job Summary

Ensures the Credentialing Plan and processes meet the needs of Sentara Health Plans' clients, payers, the market, state regulations and NCQA, Medicare/Medicaid, MCHIP, and URAC credentialing standards. Oversees development and implementation of policies, procedures and workflows. Leads the evaluation of effectiveness of the Credentialing Plan and associated processes and procedures. Ensures all health plans comply with accrediting and regulatory/legislative credentialing requirements. Directs all activities associated with the credentialing and/or re-credentialing process for all clinicians and facilities in accordance with the applicable state/federal regulations, accrediting body standards and all Sentara Health Plans policies, procedures and practices. Oversees the implementation and management of Delegated Agreements to include auditing and reporting requirements. Leads the development and implementation of credentialing activities for health plan customers, including policies, procedures, and Credentialing Committees. Acts as the business lead for the credentialing system implementation and ongoing system management.

Knowledge of credentialing software preferred
Working knowledge of Credentialing Standards required
Must be able to review and make necessary revisions in credentialing delegation agreements with external payer partners
Professional Medical Services Management Certification (CPMSM) or Professional Credentialing Specialist Certification (CPCS) is preferred

Qualifications:

BLD - Bachelor's Level Degree (Required)

Credentialing, Credentialing Management, Managed Care, Management

Skills

Communication, Complex Problem Solving, Coordination, Critical Thinking, Judgment and Decision Making, Microsoft Office

Sentara Healthcare prides itself on the diversity and inclusiveness of its close to an almost 30,000-member workforce. Diversity, inclusion, and belonging is a guiding principle of the organization to ensure its workforce reflects the communities it serves.

Per Clinical Laboratory Improvement Amendments (CLIA), some clinical environments require proof of education; these regulations are posted at ecfr.gov for further information. In an effort to expedite this verification requirement, we encourage you to upload your diploma or transcript at time of application.

In support of our mission “to improve health every day,” this is a tobacco-free environment.