Regional Manager of Credentialing and Auditing

Description

Planned Parenthood of Central and Western New York (PPCWNY) protects and provides health care and education that empowers individuals and families. With respect. Without judgment. No matter what.

Diversity and inclusion are core values at Planned Parenthood of Central and Western New York (PPCWNY). PPCWNY recruits exceptional and diverse staff. PPCWNY strives to develop staff into leaders for a diverse and global workplace.

In support of Planned Parenthood of Central and Western New York (PPCWNY)’s mission, the Regional Manager of Credentialing and Auditing is accountable for systems, processes, management and supervision of employees and oversight of contractors for Credentialing and Auditing to ensure accuracy and adherence with organizational policies and procedures, and compliance with requirements of our health plan partners and local, State, and Federal regulatory agencies.

The Regional Manager of Credentialing and Auditing will stay informed of industry trends and regulatory requirements including ICD/CPT codes, Medicare and Medicaid regulations as well as having a clear understanding of laws impacting utilization management of credentialing for government health plans as well as auditing principals and reporting processes.

Works collaboratively with Revenue Cycle Leadership and Health Services Leadership, providing support direction, and research findings to develop policies and standardized processes for Credentialing and Auditing.

• Responsible for the hiring, training, direction and supervision of the Coding, Auditing and Credentialing staff including work allocation, training, and enforcement of internal procedures and controls, and problem resolution.
• Works collaboratively with Revenue Cycle Leadership to create policies and procedures for auditing, payer enrollment and credentialing.
• Develops project plans for Credentialing and Auditing, and reports quarterly to Shared Service Affiliates Compliance and Risk Management departments on the associated measures.
• Assists and supports Revenue Cycle Leadership and/or our contracted vendor with Payer contract negotiations of terms and conditions with payers to ensure favorable agreements with shared service affiliates.
• Engages in proposed revision of Third-Party payer contracts and/or consideration of new payer contracts as appropriate to meet affiliate fiscal interests.
• Works collaboratively with Revenue Cycle Leadership to evaluate Third-Party payer contracts; investigates and resolves medical claim denials related to Enrollment Credentialing, Coding, or other Payer issues to mitigate risk and optimize revenue growth.
• Stays current on changing laws and regulations related to Credentialing and Coding and identifies potential risks.

Credentialing

• Coordinates all aspects of individual provider and facility participation with health insurance carriers under their respective delegated credentialing agreements.
• Works collaboratively with Clinical Services and Human Resources to develop and implement seamless protocols for gathering Credentialing data from Providers, including expediting completion of forms, obtaining signatures, and locating required documentation.
• Interprets, communicates, and implements policies and procedures to ensure that applications are properly verified and accurately uploaded to credentialing database systems with adherence to applicable Federal, State, and/or Payer guidelines.
• Supervises the management and functions of Credentialing staff and/or contracted personnel to ensure all Shared Services Affiliate Providers are enrolled, credentialed, and revalidated timely with Medicaid, Medicare, and all contracted Third-Party Payers in accordance with guidelines set forth in the Credentials Verification Organization (CVO) policy and accreditation standards for Planned Parenthood Federation of America (PPFA).
• Develops and maintains relationships with payer representatives through meetings, telephone interactions, and written correspondence to enhance provider enrollment, contractual obligations, and understanding of carrier system workflows and policies.
• Defines and implements processes to maintain accurate and up-to-date Credentialing statuses, renewal requirements and timelines to ensure Credentialing revalidation functions are performed prior to expiration for Providers and with contracted Payers.
• Analyzes data and reports on applications and credentialing status to identify trends and makes recommendations to improve the credentialing processes, contract utilization, and financial outcomes.

Auditing