Company Statement
For the last 80 years, EmblemHealth has been taking care of New York’s heart and soul, its people. Today, health care is more complex than ever. That’s why we’re at the forefront of change. We work alongside our customers to offer access to high-quality, affordable care, help navigate the health care experience, and make good health achievable; because everyone deserves to be taken care of. We deliver on our mission every day by living our values with our colleagues, members, clients and partners. It begins with caring and respecting all those we work with. We believe a culture of diversity and inclusion is vital to serve our unique and diverse customers. We seek for continues improvement and innovation and believe being agile and nimble is our advantage. We bring a strong sense of partnership to every relationship – internally and externally. The EmblemHealth family of companies offers competitive health, welfare, and retirement benefits as well as incentive pay plans and more.
Director, Credentialing
Summary:
- Manage the credentialing process for all medical staff providers, in accordance with The Joint Commission, NCQA, and CMS accreditation standards, and Federal and State Laws.
- Responsible for credentialing analysis, quality assurance, planning, client/vendor relationships and continuous improvement of operational performance.
- Accountable to drive, monitor, and enhance oversight of quality, analytics, and auditing of vendor (Cognizant and other) performance to ensure contractual adherence in both operational and compliance SLAs, quality and timeliness standards.
- Oversee validation of vendor performance reporting and daily operations.
- Accountable to drive, monitor, and enhance Credentialing Delegation oversight, including onboarding of delegates and performance management in synchronicity with regulatory and enterprise policies. Implement process initiatives in alignment with regulatory and enterprise requirements as needed. Develop standardized enterprise processes that incorporates regulations and requirements for EmblemHealth’s Family of Companies.
- Lead and participate in system configuration and new product or process initiatives. Serve as a deciding body in all phases. Execute process and policy changes in accordance.
Responsibilities:
- Analyze and implement process improvements to enhance efficiency of credentialing.
- Conduct on-going program evaluations and audits of data integrity.
- Ensure accurate outcomes and compliant procedures to meet service goals.
- Coordinate with practice management, licensing agencies, insurance carriers, and other appropriate organizations to complete credentialing and re-credentialing applications
- Manage staff including interviewing and selecting qualified candidates, coaching for career development, training, monitor productivity and accuracy, conduct performance evaluations, guidelines and changes, consistent application of HR policies and procedures, and guide staff to confident decision-making.
- Support, participate and contribute to the development and growth of credentialing functions.
- Work with various departments to ensure a smooth transition of providers when on-boarding, for new contracts and during acquisitions.
- Drive and monitor oversight of vendors’ (Cognizant and other) quality performance for each core process of Credentialing and Delegation to meet contractual requirements and align with regulatory mandates and enterprise-wide (EH and CCI) customer experience objectives and overall corporate strategic direction. Validate and trend reported quality performance results through independent reporting and audit-the-auditor reviews.
- Quantify and validate vendor quality performance by conducting and monitoring on-site and transactional audits, policy and procedure verifications, quality program verifications, adhoc reporting and compliance adherence reviews. Monitor regulatory execution and reporting for sanction and exclusion processing and OMT reporting.
- Lead and develop direct reports to continuously conduct on-site and transactional audits, ad-hoc reporting and compliance adherence reviews. Participate and coordinate in regulatory audit response preparation and audit conveyance. Develop and maintain policy and procedure documentation in accordance with current processes.
- Participate in Credentialing/ReCredentialing Committee meetings, ensuring vendor participation and preparation, and converse with Medical Directors as needed. Ensure preparedness for and participate in Monthly Delegation Oversight Committee (DOC) Meeting.
- Identify opportunities for process improvement, systematic enhancements, and standardization of departmental practices across the enterprise of initial and re-credentialing, regulatory compliance and delegated credentialing oversight. Work with all levels of management and staff to implement changes that enhance the customer experience and operational workflow in support of enterprise objectives.
- Lead and participate in internal and external interdepartmental meetings to maintain and expand business process efficiency, issue management and staff education or training.
- Proactively and clearly communicate milestones, status, selling of ideas and proposals. (use Executive Briefing Tool
Requirements:
- BS or BA degree required
- Certified Provider Credentialing Specialist (CPCS) and Certified Professional in Medical Staff Service Management (CPMSM) is preferred
- 10+ years of relevant professional experience in credentialing and 7 years in a leadership capacity required
- 5+ years of experience in Quality Mgmt. & Improvement, Change Management, and Customer Experience preferred
- Track record of successfully managing large, high impact projects preferred
- Ability to lead, develop, mentor, and manage staff to achieve departmental and organization goals and objectives required
- Knowledge of delegated credentialing and verification, and related accreditation and certification, requirements required
- Knowledge of medical credentialing procedures and standards required
- Extensive experience with and knowledge of CAQH and credentialing processes required
- Energy, drive and passion for End-to-End excellence and customer experience improvement required
- Excellent collaboration skills and the ability to influence management decisions required
- Strong problem solving and analytical skills that can be applied across all types of business problems required
- Strong communication skills (verbal, written, presentation, interpersonal, facilitation) required
- Solid coaching and mentoring skills to continuously develop staff core competencies at vendors required
- Demonstrated Customer Experience focus and 1 year of process improvement experience required
- Ability to work with physicians in a collaborative manner required
- Ability to create, implement, document and audit policies and procedures required
- Ability to manage direct/indirect/remote employees to ensure internal controls are followed required
- Ability to effectively prioritize and execute tasks in a high-pressure environment required
Security Disclosure
If you are offered a job from one of the EmblemHealth family of companies that includes ConnectiCare, AdvantageCare Physicians, and WellSpark, the offer confirmation email will come from “HRTalentAcquisition” with the subject line: “Offer of Employment for (job title)” – Please respond online”.
We never ask you to join a Google Hangout, request you to purchase your own equipment or pay to apply. We do not send email from a third-party email service such as Yahoo or Gmail.
Pay Disclosure
A good faith estimate of the compensation range for individuals hired to work for the EmblemHealth Family of Companies is provided. This compensation range is specific and considers factors such as (but not limited to) the scope and responsibilities of the position, the candidate’s work experience, education/training, internal peer equity, and market and business considerations. The disclosed range estimate has not been adjusted for the applicable geographic differential associated with the location at which the work is being performed. It is not typical for an individual to be hired at or near the top of the range, as compensation decisions depend on each case’s facts and circumstances. Union roles covered by a collective bargaining agreement will compensate in accordance with the union contract.
EEOC Statement
We are committed to leveraging the diverse backgrounds, perspectives, and experiences of our workforce to create opportunities for our people and our business. We are an equal opportunity/affirmative action employer, and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex/gender, sexual orientation, gender identity or expression, pregnancy or related condition, marital status, national origin, disability, protected veteran status or any other characteristic protected by law.
Sponsorship Statement
Depending on factors such as business unit requirements, the nature of the position, cost and applicable laws and regulations, EmblemHealth may provide work visa sponsorship for certain positions.