Credentialing Team Leader
PacificSource

Job Info

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Looking for a way to make an impact and help people?

Join PacificSource and help our members access quality, affordable care!

PacificSource is an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to status as a protected veteran or a qualified individual with a disability, or other protected status, such as race, religion, color, national origin, sex, sexual orientation, gender identity or age.

Diversity and Inclusion: PacificSource values the diversity of the people we hire and serve. We are committed to creating a diverse environment and fostering a workplace in which individual differences are appreciated, respected and responded to in ways that fully develop and utilize each person's talents and strengths.

Responsible for directing all Credentialing, Provider Data, and Delegated Credentialing functions while managing the daily operations of the credentialing team including selection, training, and supervision of staff. Provide direction and guidance regarding company policies, procedures, and workflow. Manage production and quality, implementing performance measures and developing productivity reports. Ensure credentialing adherence to NCQA or other company certification requirements. Demonstrate effective leadership by coaching to improve individual performance, develop teamwork and team support, manage change and encourage innovation, build collaborative relationships, encourage involvement and initiative, and develop increased vision and commitment to goals in others.

Essential Responsibilities:

• Responsible for all PacificSource credentialing and recredentialing activities and the ongoing development of the credentialing program, including implementing changes to existing policies and processes to accommodate changes in NCQA credentialing guidelines and State and Federal regulatory standards.
• Coordinate and perform all credentialing activities related to credentialing operations.
• Organize project work, maintain inter-departmental contacts on credentialing issues, and develop and maintain credentialing status reports, metrics, and demonstrated achievement of objectives in PRISM walks.
• Coordinate monthly Credentialing Committee meetings including collaboration with Chief Medical Officer and Credentialing Committee Chair in developing agenda and other materials to ensure items are presented appropriately and followed up with as needed.
• Delegate Credentialing Team's role and responsibilities related to participation in monthly Credentialing Committee meetings.
• Ensure credentialing compliance of entities delegated to perform credentialing activities for PacificSource.
• Monitor the delegates to ensure continued compliance with PacificSource credentialing standards, NCQA standards, and State and Federal regulatory requirements.
• Collaborate with contracting to engage in new delegated credentialing relationships with provider partners.
• Perform pre-delegation assessment of delegate to ensure entity meets standards of PacificSource, NCQA, and State and Federal Regulatory bodies and is aware of the ongoing responsibility of delegated credentialing.
• Complete audits of delegates including performing a site visit, review of credentialing and recredentialing files, credentialing policy and procedure review, and overall review of the delegates' credentialing program at a minimum annually to ensure each entity is meeting NCQA standards and State and Federal Regulatory requirements.
• Coordinate complete execution of delegation agreement including negotiation process prior to execution of contract.
• Maintain collaborative relationships and act as a liaison for PacificSource with IPAs, medical groups, and other health plans.
• Manage training and orientation of new hires.
• Maintain broad knowledge of all assigned positions and develop programs to assure ongoing training and coaching to assigned staff.
• Assist Vice President of Provider Network in department strategic planning.
• Directly responsible for developing and revising credentialing policies to ensure PacificSource is meeting NCQA and State and Federal regulatory standards as it relates to credentialing.
• Serve as liaison with all PacificSource departments to coordinate optimal provision of service and information.
• Serve on various interoffice committees as well as external workgroups.
• Document and report any pertinent communications back to the Management team, credentialing team, or department.
• Work collaboratively with Provider Network Team Leader(s) and Manager(s) to develop department best practices and address issues.
• Cover other team members for absences.
• Maintain knowledge of legislative statutes and rules related to credentialing standards and processes and perform updates accordingly.
• Communicate changes to credentialing team, provider network department and other pertinent areas in the company.
• Serve as Administrator for credentialing software, including software development, data conversion, implementation, software updates and enhancements and staff training.
• Directly responsible for policy development, revision, process implementation and overall credentialing program operations in order to achieve and maintain compliance with NCQA and State and Federal regulatory bodies.
• Research and analyze provider scope and licensure including State administrative statutes and rules to ensure appropriate classification of provider types.
• Responsible for oversight, management, development, implementation, and communication of department programs.
• Responsible for hiring, staff development, coaching, performance reviews, corrective actions, and termination of employees.
• Provide feedback, including regular one-on-ones and performance evaluations, for direct reports.
• Develop annual department budgets.
• Monitor spending versus the planned budgeted throughout the year and take corrective action where needed.
• Coordinate business activities by maintaining collaborative partnerships with key departments.
• Responsible for process improvement and working with other departments to improve interdepartmental processes.
• Utilize lean methodologies for continuous improvement.
• Utilize visual boards and daily huddles to monitor key performance indicators and identify improvement opportunities.
• Actively participate in various strategic and internal committees in order to disseminate information within the organization and represent company philosophy.

Supporting Responsibilities:

• Meet department and company performance and attendance expectations.
• Follow the PacificSource privacy policy and HIPAA laws and regulations concerning confidentiality and security of protected health information.
• Perform other duties as assigned.

Work Experience: Minimum of two years of experience in a health insurance area, preferably credentialing. Equivalent work and education experience will be considered. Strong experience in problem resolution and associated research required. Prior supervisory experience preferred.

Education, Certificates, Licenses: High school diploma or equivalent required. CPCS and/or CPMSM certification encouraged.

Knowledge: Understand NCQA standards. Effective written and verbal communication skills. Excellent interpersonal skills. Ability to work under time pressures and heavy workloads. Requires ability to define and prioritize problems and manage workload without direct supervision. Strong computer skills in Microsoft Windows based software. Exceptional organizational skills. Consistently helpful, confident, and pleasant with all types of customers, both internal and external. Maintaining current on PacificSource business processes and procedures and conveying that information to team members. Proactive approach to ensure quality service.

Competencies:

Adaptability

Building Customer Loyalty

Building Strategic Work Relationships

Building Trust

Continuous Improvement

Contributing to Team Success

Planning and Organizing

Work Standards

Environment: Work inside in a general office setting with ergonomically configured equipment. Travel is required approximately 10% of the time.

Skills:
Accountable leadership, Collaboration, Communication (written/verbal), Critical Thinking, Decision Making, Influencing, Listening (active), Organizational skills/Planning and Organization

Our Values

We live and breathe our values. In fact, our culture is driven by these seven core values which guide us in how we do business:

• We are committed to doing the right thing.
• We are one team working toward a common goal.
• We are each responsible for customer service.
• We practice open communication at all levels of the company to foster individual, team and company growth.
• We actively participate in efforts to improve our many communities-internally and externally.
• We actively work to advance social justice, equity, diversity and inclusion in our workplace, the healthcare system and community.
• We encourage creativity, innovation, and the pursuit of excellence.

Physical Requirements: Stoop and bend. Sit and/or stand for extended periods of time while performing core job functions. Repetitive motions to include typing, sorting and filing. Light lifting and carrying of files and business materials. Ability to read and comprehend both written and spoken English. Communicate clearly and effectively.

Disclaimer: This job description indicates the general nature and level of work performed by employees within this position and is subject to change. It is not designed to contain or be interpreted as a comprehensive list of all duties, responsibilities, and qualifications required of employees assigned to this position. Employment remains AT-WILL at all times.

This job has expired.