Stormont-Vail Healthcare Provider Enrollment Supervisor in Topeka, Kansas

Summary:

A member of the Medical Staff Services management team with primary responsibilities, which include the management of Provider Enrollment, functions and who also, assists the director with special assignments. This is a project management orientated position that assists the director in the broad spectrum of responsibilities such as the development, planning and operational management of the medical and health practitioner payer and affiliation credentialing/ reappointment program and oversees accurate and timely coordination of the payer and affiliation enrollments for credentialing completion.

Responsible for initial and reappointment of Stormont Vail Health Medical Services Division employed practitioner’s (physicians, advanced practice professionals and allied health professionals) participation in health insurance network and other hospital affiliations as directed. The provider enrollment process will include enrollment and unenrollment applications/process through delegated and non-delegated contracted plans with completion of required documents, which may include a credentialing application, enrollment forms, unenrollment and other payer specific requirements.

Essential Duties and Responsibilities include the following. Other duties as assigned.

  • Assist the Director with the daily operations of the provider enrollment functions to develop and monitor processes and procedures that support provider enrollment credentialing and re-credentialing processes for payer panels and other provider affiliations.

  • Performs functions and duties as a supervisor to include but not limited to management of staff schedules, API, BOA, hiring.

  • Responsible for the timely entry,processing and tracking of credentialing files to include productivity and quality management

  • Assists director by providing information pertinent to completion of annual competency evaluation

  • Maintain confidentia lcredentialing files and electronic credentialing database.

  • Review credentialing files for accuracy andcompleteness.Performs primary source verification o fpractitioner credentials based on the policies and procedures ofStormont Vail Health and the federal and state regulatory agencies and accrediting bodies.To include but not limited to National Committee for Quality Assurance(NCQA),Centers for Medicare & Medicaid Services(CMS), Utilization Review Accreditation Commission (URAC) and Joint Commission (JC).

  • Monitor and assis tfurther investigations as deemed necessary during the credentialing process by document evaluation,primary source verifications or as requested.

  • Prepare initial credentialing and re-credentialing files for the Medical Director and/or the Credentials Committee.

  • Ability to complete an assigned # of practitioner and/orfacility files per month and meet the departmental performance target.

  • Responsible for auditing 20% of initial and 20% of all reappoint credentialing files, reviewing and reporting compliance data to the Credentialing Supervisor for payer panel audits.

  • Responsible for auditing 20% of initial and 20% of all reappoint payer panel files, reviewing and reporting compliance data to the Director and developing coaching and improvement plans as indicated.

  • Data analysis and report to Director quality reports and TAT

  • Monitor and conduct ongoing monitoring reports as required by the accrediting and regulatory bodies.

  • Work closely with multiple departments to include Phys. Support Services, Billing, and Credentialing to insure the credentialing application process is efficient and meets established turnaround times.

  • Responsible in preparing and overseeing the payer delegated credentialing audits as required by NCQA, URAC and JC.

  • Attend and participate in Medical Staff Services Dept. credentialing staff meetings.

  • Communicates change(s) for employed physicians, midlevel practitioners, and others for billing under the TINS.Assist Contract Department and Billing to complete facility applications with payer panels.

  • Maintains current list of contact information for third party payers.

  • Coordinate with third party vendors to ensure the implementation of standardized forms

  • Prepare communication outlined by Director from oral or written directions.

  • Creates and maintains word-processing, presentations, database, and spreadsheet files; uses other computer applications as required.

  • Design, implement and maintain filing and records management systems and other office flow procedures, ensuring that information and records are easily accessible; Database management in CACTUS

  • Assist supervised provider enrolment staff where needed with creating unity as a team player. Must be able to reorganize schedule to accommodate workload demands of coworkers and provide phone coverage in department.

  • Attend and participate in recruitment visits.

  • Maintain a professional appearance and maintain a neat and well-organized workplace.

  • Interacts with credentialing representatives of third party payer and affiliations to problem solve issues involving employed physician’s application information.

  • Maintains application tracking and provides weekly report to Director regarding status of newly employed physicians and allied health practitioners concerning the managed care/ affiliation credentialing process.

  • Provides weekly report to Director regarding status of those employed providers currently in the reappointment process with third party payers or other outside entities.

  • Initiates termination of managed care contracts for terminating providers.

  • Regularly attends and participates in AMC.

  • Oversees preparation and distribution of monthly report for delegated agreements.

  • Serveaspoint ofcontactforCenterandPlanstaff regardingcredentialingissues.

  • Participate in the development and implementation of departmental policies, procedures, forms, etc.

  • Perform site visits as necessary or requested.

  • Ability to take a lead role in assisting with accreditation audits in the absence of the Director or at her direction

  • Ability to train/orient new employees of the Credentialing Department on how to process initial, re-credentialing and facility credentialing applications,and enter them into the company databases.

  • Monitor and audit completed files in the Credentialing Department a swell as audit 100%of new team member’s files to ensure employee is consistently applying NCQA/CMS/URAC/JC credentialing guidelines while processing applications.

  • Ability to report to work on time and work the days scheduled is essential to this position.

  • Ability to work closely with Administration, Contracting Department and Billing to participate in ACO, NPI, EHR, QBRP Reporting.

  • Assists the Director with performance evaluation of supervised staff

  • Attend management educational courses offered by Stormont Vail Health

  • Establish and maintain harmonious working relationships with superiors, co-workers, physicians, and customers.

    Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience:

Associate’s degree required. Bachelor’s degree preferred. Minimum two (2)years’ experience in a healthcare delivery environment or three(3) years in credentialing activities. Proficiency in taking meeting minutes and ability to transcribe accurately required.

Memberships: Kansas Association of Medical Staff Services (preferred).

Certificates and Licenses :

Certified Provider Credentialing Specialist (CPCS) preferred.

Language Ability:

Ability to read, analyze and interpret general business periodicals, professional journals, technical procedures, legal, accrediting and regulatory information. Demonstrate excellent writing skills to develop and write business correspondence, reports and procedure manuals accurately and in accordance with recognized standards (grammar, punctuation) for the English language. Exhibit oral communication skills (tact, diplomacy etc.) to present and respond to information for a broad audience including, but not limited to, managers, physicians, outside regulatory agencies, customers and the public. Ability to understand and communicate utilizing appropriate medical terminology. Demonstrates respect for all individuals (visitors, peers, customers and team members) and helps create and maintain teamwork within the work environment, which contributes to meeting the goals and objectives of the Medical Staff Services department and reflects the mission and values of Stormont Vail Health.

  • Good oral and written communication skills.

  • Ability to meet scheduled deadlines with minimal supervision.

  • Strong organizational skills and accurate work results.

  • Ability to maintain a professional demeanor and confidentiality.

  • Maintain knowledge of NCQA, CMS, URAC, and JC State and Federal regulations related to health plan credentialing activities.

  • Experience in creating performance data reports and setting meeting agendas.

  • Detail oriented.

  • Accomplish responsibilities accurately and expeditiously.

  • Ability to multi-task and deal with complexity on a frequent basis.

  • Flexible, teamplayer.

  • Self-starter and self-motivated, functions independently with minimal direction.

  • Wordprocessing and database computer skills, including Word and Visual Cactus, preferred.

  • Must be able to work with a variety of people and circumstances.