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Posted: Sunday, July 30, 2017 12:06 AM

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Position Objective
Under limited supervision, oversees the Credentialing Operations at Physician Health Network to develop, manage and monitor processes and procedures that support the credentialing, re-credentialing, data management, and delegated credentialing contract processes. Oversees all of the credentialing functions; including application management and primary source verification. Ensures compliance with the appropriate regulatory bodies. Supervises credentialing staff in the day-to-day management of the overall credentialing process and database management.

Duties and Responsibilities
Manages the credentialing process for all Physician Health Network providers, in accordance with Credentialing Governing Bodies and Health Plan standards.
Coordinates the management of the credentialing database to ensure accuracy of data and reporting.
Ensure proper processes are in place and monitor turnaround times for processing of credentials applications, with continued focus on delivery of a high quality product, with the greatest efficiency, in the least amount of time.
Monitor expirables to ensure current licensures are on file for contracted providers.
Monitors the currency of Credentialing Policies and Procedures to ensure compliance with Governing Bodies requirements and changes.
Prepares for and coordinates credentialing audits in compliance with the managed care delegated credentialing contracts and respond to auditor’s inquiries and prepare responses to findings, if applicable.
Responsible for reviewing On-going Monitoring Reports and take the necessary steps if network provider is identified.
Prepare Agenda, Minutes and Conduct Final review of Credentialing Files, prior to Committee.
Notify contracted Health Plans of all Provider Network Changes to include; additions, terms etc.,
Functions as primary credentials contact for all internal and external inquiries; develops and maintains positive working relationships.
Oversees the supervision of Credentialing Staff, which includes work allocation, training, enforcement of internal procedures and controls, and problem resolution; evaluates performance and makes recommendations for personnel actions; motivates employees to achieve peak productivity and performance.
Notify providers of Credentialing Committee decisions.
Submits Credentialing semi-annual/ quarterly reports to contracted Health plans.
Responsible for the Review/ Approval of Organizational Providers.

Minimum Job Requirements
Completed degree(s) from an accredited institution
Or; at least five (5) years supervisory or management level experience in managed care or credentialing oversight.
NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing certification.

Knowledge, Skills and Abilities Required
Ability to investigate and analyze information and draw conclusions.
Ability to develop and deliver presentations.
Ability to process computer data and to format and generate reports.
Ability to supervise and train employees, to include organizing, prioritizing, and scheduling work assignments.
Ability to communicate effectively, both orally and in writing.
Skill in developing policy and procedure documentation.
Ability to conduct oversight of Delegated Credentialing process
Ability to plan, assign, train, supervise and evaluate the work of others, and to monitor goals, objectives, deadlines and priorities;
Ability to establish and maintain effective and cooperative working relationships with staff and others contacted in the course of the work;
Ability to assume responsibility and exercise good judgment in making decisions within the scope of authority of the position;
Ability to think and work effectively under pressure and accurately complete tasks within established times;
Extensive knowledge of credentialing procedures and governing bodies standards.

Work Environment and Physical Demands
Limited exposure to physical risk.
Limited physical effort required.
Work is normally performed in a typical interior/office work environment.
Ability to sit in front of and operate terminal for extended periods of time.
Ability to lift, carry or move objects of varying size weighing up to 10 pounds.
Ability to travel.
All employees are expected to comply with Physician Health Network safety requirements.
Adhere to all Physician Health Network policies and procedures.

Email Address: apodgorska@ppmcinc.com
Phone: 9512807711
Fax: 9513728249

• Location: Corona, Inland Empire

• Post ID: 124497318 inlandempire
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