Credentialing Lead (Hybrid - Troy, MI) - Health Alliance Plan

Under minimal supervision, responsible for identifying and maintaining up-to-date knowledge of NCQA, CMS standards & DIFS requirements as they relate to the credentialing function, as well as HAP & HAP Midwest Health Plan credentialing departmental policies and procedures. Assess organizational/ancillary behavioral medicine facilities application before contracting and at least every three years thereafter for behavioral medicine facilities Provide functional oversight of credentialing staff.

PRINCIPAL DUTIES AND RESPONSIBILITIES:

• Educate and train credentialing staff to ensure compliance with the regulatory and accreditation standards as well as HAP & HAP Midwest Credentialing departmental policies and procedures.
• Responsible for ensuring that the credentialing policies, procedures, and processes within the HAP and HAP Midwest Health Plan credentialing department conform to current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
• Ensure that entities which HAP and HAP Midwest Health Plan has signed delegation agreements are in compliance current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
• Advise the Manager of Credentialing about any standards changes substantial enough to require the installation of new procedures/staff training.
• Review delegated credentialing audits tools for compliance
• Assess issues that are identified from annual delegated audits. Analyze identified issues and implement resolution in a timely manner and in accordance with regulatory standards.
• Review and evaluate organizational/ancillary behavioral medicine facilities
• Confirms that the organizational/ancillary provider is in good standing with state and federal regulatory bodies.
• Confirms that the organizational/ancillary provider has been reviewed and approved by an accrediting body.
• Request onsite quality assessment if the organizational/ancillary provider is not accredited.
• Serves as a process expert to assist to ensure compliance with current National Committee for Quality Assurance (NCQA) Standards, as well as relevant state and federal regulations.
• Prepare and coordinate documents for NCQA, CMS & DIFS audits
• Oversees the delegates credentialing/re-credentialing work responsibilities ensuring that there is accurate and timely credentialing data.
• Oversees the Physician Analysts II activities regarding delegation.
• In the absence of the Credentialing Manager assumes responsibilities for coordinating activities of the Credentialing Department.
• Assist in ensuring that the Department goals and standards are met.
• Perform other related duties as assigned.

EXPERIENCE / EDUCATION REQUIRED:

• Associate's degree is required OR four (4) years of related experience in lieu of degree. Bachelor's degree preferred.
• Minimum of five (5) years of experience in health care industry, managed care setting in credentialing and re-credentialing, processes; credentialing database and associated activities.
• Minimum of one (1) year experience with the application of NCQA standards and oversight of credentialing delegation.
• At least one (1) year experience in the use of physician credentialing database (e.g., Cactus and other software packages (e.g. Word, Excel, PowerPoint, Access or similar database).
• Minimum of five (5) years of experience in physician credentialing preferred.
• Knowledge of credentialing software.
• Knowledge of NCQA,CMS Standards& DIFs requirements.
• Ability to work under minimal supervision.
• Ability to perform detail work efficiently and with a high degree of accuracy.
• Excellent problem-solving skills.
• Highly organized.
• Ability to initiate and coordinate multiple projects simultaneously.
• Excellent verbal communication skills.
• Ability to interpret information and make judgment quickly.
• Ability to interact professionally with practitioners and other external customers.
• Strong quantitative and analytical skills.
• Computer proficient in Microsoft Office including; Word and Excel.
• Knowledge of the principles and practices of credentialing is highly desirable.
• Knowledge consistent knowledge of Department policies and processes.

• Organization: HAP (Health Alliance Plan)
• Department: Provider Network Operations
• Shift: Day Job
• Union Code: Not Applicable