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

GENERAL SUMMARY:

Oversees and coordinates the delegates credentialing/re-credentialing work responsibilities and work processes to ensure maximum efficiency and quality. Provide functional oversight of credentialing staff. Coordinates and assists the Physician Credentialing Analysts II in the delegation workflow process. Assists in the development, implementation, and oversees the credentialing auditing and error reporting processes and procedures. Assess organizational/ancillary provider application before contracting and at least every three years thereafter for Hospitals, Home Health Agencies, Skilled Nursing Facilities and Ambulatory Surgical Centers. Serves as a backup for the Credentialing Manager.

PRINCIPLE DUTIES AND RESPONSIBILITIES:

• 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.
• Reviews delegation reports - i.e., approvals, terminations or waivers, submitted by the Physicians Credentialing Analysts II.
• Coordinates annual delegated and pre-delegated audits.
• Review and evaluate organizational/ancillary providers.
• 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 resource to the Credentialing Manager, Credentialing and Credentialing Oversight Committees and staff for technical and procedural issues in the investigation of individual credentials and qualifications of physicians and other practitioners/providers; and for enhancement of work methods and systems; and the use of technical resources.
• In the absence of the Credentialing Manager assumes responsibilities for coordinating activities of the Credentialing Department.
• Tracks key performance indicators, report them regularly, and identify opportunities for improvement.
• Assists in the training of staff on credentialing, re-credentialing, Cactus processes.
• Research new or alternative sources of information to improve the credentialing process and meet HAP, NCQA, CMS, State, HIPAA and all other regulatory
  standards; assist in research and development of policies and procedures.
• Serves as a process expert to assist in updating credentialing and re-credentialing policies and procedures.
• Assist in ensuring that the Department goals and standards are met.
• Performed other related duties as assigned.