This position is responsible for providing leadership in the development, implementation and oversight of all Provider Data and Credentialing functions in alignment with organizational strategic initiatives while ensuring a collaborative, open and inclusive work environment that is focused on quality outcomes and superior customer service. Accurate provider data and credentialing is central to pay or organizations so this position must drive for timely data processing with highest degree of accuracy possible. This position serves as the primary advisor to the organization and subject matter expert on matters related to assigned area of responsibility. Also directs, plans, develops, and implements performance standards, quality improvement, and delivery of service to create a positive impression of TriWest with its providers. This position is responsible for serving as a role model throughout the organization and representing TriWest in a positive manner both within and outside the organization.
• Responsible for leading the Provider Services Provider Data Management and Credentialing Department of ~30-40 staff members and supervisors.
Provides leadership and direction to ensure department adherence to established performance metrics.
Optimizes individual team member performance through mentoring and coaching.
• Manages the entry of data into the provider master database which houses all network provider information.
Coordinates and monitors data entry interface from outside organizations and oversees the maintenance of up-to-date information, including provider demographic data, contracting, provider directory, and status information.
Oversees and directs the source verification and data entry process.
Develops key performance reports/dashboards to communicate department performance to senior leadership and other key areas within the organization.
• Ensure the accuracy of all network provider data which exceeds industry standards.
• Identify, implement and maintain several systems as the business owner to support the necessary functions within the department.
• Leads database enhancement initiatives and IT interface on database and system changes.
Develops and maintains standards for data integrity and identifies system issues integral to problem resolution.
• Oversees, develops, and directs the implementation of credentialing and re-credentialing policies to meet contract (e.g. Department of Veterans Affairs) and accreditation (e.g. URAC) requirements.
Oversees and implements credentialing audit plan with the network subcontractors and other delegated entities.
Reviews and reports the results of audits to the Corporate Clinic Quality Management Committee.
Oversees the implementation of strategic plans and reinforce working with providers to meet or exceed network targets.
Manages the annual review of credentialing policies and procedures to ensure accuracy and compliance with contract and accreditation requirements.
• Develops strong network provider relationships and work towards effective identification and timely resolution of provider data processing issues. Ensures timely responses to provider questions and issues.
Resolves reoccurring issues through appropriate problem identification and new strategies.
Develops process improvements and implementation plans for workflow procedures and service levels.
• Responsible for ensuring all network provider contract terms are loaded into the appropriate systems to allow for accurate authorization and referral management and claims processing.
• Defines staffing needs and allocates resources to achieve service objectives.
Selects staff, orients, trains, coaches, and develops staff.
• Determines budgetary requirements for meeting department objectives. Recommends annual budget and supporting business cases for system enhancements. Forecast resource requirements in response to industry trends and developments.
• Works collaboratively with external entities to ensure continuous quality improvement.•
Regular and reliable attendance is required.
Education & Experience
• Bachelors degree in Business Administration, Health Care or related field or equivalent experience
• 5 years experience in a Managed Care environment
• 5 years management experience in the healthcare industry
• At least 3 years experience with provider data management, credentialing and/or provider services operations
• Ability to manage large numbers of staff in a production environment
• Experience in strategic planning, program management/implementation, and staff development
• Experience with URAC , NCQA or other equivalent accreditation standards
• Experience in government healthcare delivery programs, such as Veterans Affairs, TRICARE and Medicare
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