Manager Provider Credentialing & Enrollment

Jefferson Health Plans • Philadelphia, PA

23h • Onsite

About The Position

Responsible for the operations of Jefferson Medical Group (JMG) Central Enrollments department (health plan enrollment) and physician credentialing function. This includes management of the Delegated Credentialing process by contractual obligations with major health plans; as well as direct oversight of the Delegated Provider Enrollment process, this management encompasses all credentials data and related documentation, scanning and maintenance of files for JMG physicians including the Management Services Organization (MSO) outside clients who pay for the services of JMG Central Enrollments.
Responsibilities: Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson Manage staffing levels, workload allocation, and quality improvement initiatives for JMG Central Enrollments Department for both health plan enrollment as well as all Delegated Credentialing processes with designated health plans. Proactively manage all credentialing and enrollment processes and ensure that systems meet the needs of credentialing staff and that staff adhere to department standards regarding data integrity and confidentiality. Manage all communications of physician data to the various health plans regarding the structure and makeup of groups, practice names, tax identification numbers, NPIs, and practice site addresses for both JMG and MSO clients. Develop, implement and monitor departmental standards and procedures related to hard copy files, scanning, and linking documents, data entry, storage and retrieval for their JMG physician database. Primary liaison between Medical Staff Affairs Office (TJUH), JeffCARE (PHO), JMC Faculty Affairs, Jefferson Medical GroupAdministrative Office, and JMG Physician Business Services. This includes coordination and distribution of provider numbers and enrollment data from contracted health plans to internal departments and submission to the EPIC billing system. Review all delegated health plan contract language under negotiation regarding operational issues and compliance with all external (NCQA, Federal, HHS, DPW, and health plans) as well as all JMG internal policies and procedures. Develop and implement processes to incorporate all new delegated plans as they become contracted into current JMG processes including data exchanges, reporting, and identifying any necessary changes in the JMG physician Cactus database. Oversight of the Primary Source Verification process for credentialing providers. Ensure that credentialing staff meets strict timelines with an expected accuracy of documentation for presenting delegated credentialing file for approval at the monthly Credentialing SubCommittee meeting. Manage the enrollment and credentialing process of JMG physicians as well as Management Services Organization outside clients who pay for the services of JMG Central Enrollments. This includes oversight of credentialing staff for timely completion of various health plan applications, internal tracking of credentialing and enrollment process, ensure routine follow-up contact with health plans on mailed applications, and communication with Department Chairman, Administrators, and Key Contacts regarding the status of physicians in the process.

Requirements

• Minimum 2 years supervisory experience, preferably in a position involving physician enrollment/credentialing and billing.
• Extensive experience and knowledge of managed care enrollment and contracting procedures and its impact to revenue cycle.
• Credentialing software experience.
• Understanding of NCQA guidelines for credentialing, primary source verification process, PA State, Medicare and Medicaid enrollment guidelines, physician sanctions review.
• Strong organizational skills.
• Ability to maintain confidential information.
• Ability to deal with multiple tasks and to be flexible regarding priorities and deadlines.
• Excellent interpersonal and communication skills, including group leadership abilities.
• High School Diploma, Associate or Bachelor Degree

Nice To Haves

• Minimum (2) years of healthcare credentialing/billing experience required.
• Minimum 3 years customer service and managed care contract experience.

Responsibilities

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson
• Manage staffing levels, workload allocation, and quality improvement initiatives for JMG Central Enrollments Department for both health plan enrollment as well as all Delegated Credentialing processes with designated health plans.
• Proactively manage all credentialing and enrollment processes and ensure that systems meet the needs of credentialing staff and that staff adhere to department standards regarding data integrity and confidentiality.
• Manage all communications of physician data to the various health plans regarding the structure and makeup of groups, practice names, tax identification numbers, NPIs, and practice site addresses for both JMG and MSO clients.
• Develop, implement and monitor departmental standards and procedures related to hard copy files, scanning, and linking documents, data entry, storage and retrieval for their JMG physician database.
• Primary liaison between Medical Staff Affairs Office (TJUH), JeffCARE (PHO), JMC Faculty Affairs, Jefferson Medical GroupAdministrative Office, and JMG Physician Business Services. This includes coordination and distribution of provider numbers and enrollment data from contracted health plans to internal departments and submission to the EPIC billing system.
• Review all delegated health plan contract language under negotiation regarding operational issues and compliance with all external (NCQA, Federal, HHS, DPW, and health plans) as well as all JMG internal policies and procedures.
• Develop and implement processes to incorporate all new delegated plans as they become contracted into current JMG processes including data exchanges, reporting, and identifying any necessary changes in the JMG physician Cactus database.
• Oversight of the Primary Source Verification process for credentialing providers.
• Ensure that credentialing staff meets strict timelines with an expected accuracy of documentation for presenting delegated credentialing file for approval at the monthly Credentialing SubCommittee meeting.
• Manage the enrollment and credentialing process of JMG physicians as well as Management Services Organization outside clients who pay for the services of JMG Central Enrollments. This includes oversight of credentialing staff for timely completion of various health plan applications, internal tracking of credentialing and enrollment process, ensure routine follow-up contact with health plans on mailed applications, and communication with Department Chairman, Administrators, and Key Contacts regarding the status of physicians in the process.

Benefits

• Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts.
• Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service.
• All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

What This Job Offers

• Job Type: Full-time
• Career Level: Manager
• Education Level: Associate degree