Senior Managed Care Credentialing Specialist - (Museum District)

Overview

At Houston Methodist, the Senior Managed Care Credentialing Specialist is responsible for leading and executing complex credentialing and payer enrollment activities, ensuring compliance with regulatory standards and payer requirements. This senior-level role mentors' junior staff, supports the onboarding and training of new team members, and provides subject matter expertise in managed care credentialing. The Senior Specialist also plays a pivotal role in special initiatives, including technology implementations and establishing new payer delegation arrangements, while maintaining a high level of accuracy, timeliness, and collaboration across departments.

Houston Methodist Standard

PATIENT AGE GROUP(S) AND POPULATION(S) SERVEDRefer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

Responsibilities

PEOPLE ESSENTIAL FUNCTIONS

• Serves as a mentor and resource to junior credentialing staff, providing guidance, support, and training.

• Facilitates onboarding and continuous education for newly hired credentialing team members.

• Effectively communicates with providers, internal stakeholders, and payers to resolve escalated credentialing issues.

• Builds collaborative relationships with departments to ensure alignment of credentialing timelines and organizational priorities. Conducts self in a manner that is congruent with cultural diversity, equity, and inclusion principles. Contributes toward improvement of department scores for employee engagement, including peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Leads the credentialing and payer enrollment process for new providers, ensuring accurate, complete, and timely submission of all documentation.

• Oversees delegation of credentialing responsibilities for assigned projects or payers, ensuring timelines and expectations are met.

• Partners with internal departments on cross-functional initiatives to improve the provider onboarding and credentialing experience.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Performs in-depth audits of provider files to ensure compliance with regulatory, payer, and organizational requirements.

• Identifies and investigates credentialing discrepancies, taking corrective actions and escalating as appropriate.

• Ensures quality standards are consistently met and leads process improvement efforts in credentialing workflows.

FINANCE ESSENTIAL FUNCTIONS

• Collaborates with Managed Care and Revenue Cycle departments to resolve payer-related delays that impact revenue cycle performance. Utilizes resources with cost-effectiveness and value creation in mind. Self-motivated to manage time effectively and prioritize tasks independently, while supporting coworkers as needed.

• Ensures documentation is submitted to payers promptly to avoid delays in reimbursement and support timely patient care delivery.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Leads or participates in the implementation of new credentialing technology or process improvements.

• Assists in launching new payer delegation arrangements and managing credentialing requirements for new contracts.

• Proact