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Director, Provider Credentialing & Data Management

Thomas Jefferson University & Jefferson Health
United States, Pennsylvania, Philadelphia
Jan 22, 2025

Job Details

Responsible for developing, documenting, and implementing standard provider data management (PDM) and credentialing policies and procedures. Directs the activities of staff that manage the PDM and credentialing functions. The Director will work closely with Operations leadership to ensure that developed standards are communicated and implemented by all company stakeholders, including key staff who rely on using critical provider data for reporting and analytics.

Job Description

  • Develop and implement a provider data governance strategy, integrating approach with various analytics teams across the organization to maximize the value of the provider data model.
  • Responsible for oversight of cross-functional and interdepartmental teams to ensure that provider data management and credentialing methodologies are consistent with the regulatory, accreditation and internal requirements.
  • Drive development and implementation of provider data interfaces, solutions, and auditable monitoring processes that include control and balance, exception handling, tracking, trending, and reporting.
  • Responsible for development, implementation, and management of operational, service, and performance metrics and proactive initiation of performance improvement activities
  • Optimize end-to-end workflows to allow for high percentage of automation, continuously improving processing turn-around times and quality of work.
  • Develop and maintain departmental policies, procedures and controls governing the credentialing process and the recording of provider data ensuring all policies and procedures and controls are in place, current, consistent across department and compliant with all legal, Federal, State, and NCQA standards.
  • Maintains up-to-date knowledge of regulations and policies related to provider enrollment and credentialing at the Federal, State and Accreditation levels and acts as the Subject Matter Expert (SME) for credentialing processes and systems, providing guidance and support to staff and internal stakeholders to ensure compliance and efficiency.
  • Oversight of the pre-delegation and ongoing delegation oversight processes related to contracted Delegated Provider entities.
  • Ensures compliance with Model Audit Rules, State, Federal and Accrediting Agencies for all elements related to provider credentialing and data entry into claims system.
  • Ensure ongoing management of provider data by overseeing and/or conducting regular audits to ensure the accuracy and integrity of provider information in provider directories, PDM and credentialing systems, collaborating data management teams to develop and implement data quality initiatives, automate data entry processes, and resolve data discrepancies efficiently.
  • Lead new business initiatives, ensuring required system configurations are planned out, implemented, tested and ready for Go Live. Ensure overall data quality, accuracy, completeness, and compliance with regulatory requirements and service level agreements.
  • Recruit, develop, motivate and retain a high caliber of team members.
  • Coach and lead team to continuously improve operational performance.
  • Maintain a positive work environment that supports self-direction; provide a structure to optimize experience, skill, knowledge and capability of the team.
  • Perform other duties as assigned.

Qualifications

Education:
  • Bachelor's degree in business, or healthcare administration, or equivalent work experience
  • NAMSS Certification (CPCS or CPMSM) highly preferred

Skills/Abilities:

  • 8 years leading an integrated credentialing and provider data management team.
  • Working knowledge of the impact of provider data on claim adjudication, authorizations, and other operational outcomes
  • Experience implementing an end-to-end provider life cycle management platform preferred.
  • Experience managing provider data in HealthEdge HealthRules Payer preferred.
  • Working experience with mainframe systems as well as PC based applications such as Excel, Access, and Word.
  • Working knowledge of and experience in developing and managing budgets preferred.
  • Excellent organizational, interpersonal, multitasking, time management and written and oral communication skills.
  • Ability to work independently and part of a team. Strong negotiation and conflict resolution skills required.
  • Process and project management ability.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.

Jefferson is committed to providing equal educational and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status.

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