Address
Form of workAwarded the Best Place to Work 2021, Blue Cross Blue Shield of Arizona helps to fulfill its mission of improving the quality of life of Arizonans by delivering a variety of health insurance products and services to meet the diverse needs of individuals, families, and small and large businesses as well as providing information and tools to help individuals make better health decisions.
This position is remote/hybrid within the state of AZ only
PURPOSE OF THE JOB
Reporting to the Chief Compliance Officer, the Director of Credentialing directs department operations, coordinates the accurate and efficient Credentialing and Recredentialing of Medicaid Business Segment providers in alignment with State, Federal, and NCQA standards, and facilitates interdepartmental process improvements.
QUALIFICATIONS
REQUIRED QUALIFICATIONS
1. Required Work Experience
- Six (6) years in health care quality focused roles
- Significant experience in credentialing/ re-credentialing and provider enrollments. Clear advancement in responsibilities and outputs is preferred.
2. Required Education
- Bachelor’s degree in Business Administration, Healthcare Administration, or in relevant field (or equivalent combination of education and experience)
3. Required Licenses
- N/A
4. Required Certifications
- N/A
PREFERRED QUALIFICATIONS
- Preferred Work Experience
- Master’s degree strongly preferred
- Preferred Education
- N/A
- Preferred Licenses
- N/A
- Preferred Certifications
- N/A
ESSENTIAL JOB FUNCTIONS AND RESPONSIBILITIES
- Oversee all aspects of the credentialing/re-credentialing of practitioners in alignment with NCQA standards. Assure compliance with CMS, AHCCCS and other regulatory entities. Also responsible for pre-delegated and annual audits of all credentialing delegated entities. Manage all activities and ensure quality related to credentialing operations and payer enrollment, and provide oversight to ensure the continued growth and development of the organization.
- Responsible for the management of the Credentialing Department: establishing, implementing, and monitoring performance goals, metrics, and processes for the Credentialing department. Prepare and maintain various reports, data, and summaries of credentialing activities.
- Train and mentor members of the team. Act as a liaison between Medicaid Business Segment and our Providers. Additionally, educate and effectively work with the credentialing team and clinicians to facilitate a seamless credentialing experience.
- Responsible for annual quality improvement reports. Prepare credentials files for presentation to committees, payers, and clients within established deadlines or appoint designee. Support Credentialing and Quality meetings on an ongoing basis; coordinating meeting times, schedules, developing agenda and presenting necessary documents for review with the respective committees.
- Review and manage provider credentialing processes to ensure that policies/workflows (desktop manuals, policy updates, etc.) are be followed in in compliance with State, Federal, and NCQA guidelines as well as contracted health plan directives.
- Identifies opportunities for improvements in the process and develops strategies to implement appropriate changes/enhancements
- Ensure compliance with regulations and contractual obligations. Effectively use financial information for strategic and operational decision making, participate in the preparation of annual budgets, and monitor performance to budget and meet agreed upon metrics
- Leads the charge in focus and implementation of the organization's culture and strategic plan in a way that aligns to the mission, vision and values of the organization.
- Develop partnerships with relevant internal and external staff; independently troubleshooting issues as they arise.
- Accountability for delegated oversight, including performing pre-delegation and annual audits to ensure compliance with the delegated credentialing agreements and regulatory standards
- Ensures Credentialing Committee(s) are coordinated and conducted in alignment with State, Federal, and NCQA standards
- Contributes to monthly AzAHP calls and facilitates process improvement initiatives among MCO’s
- Ensures policies and procedures, DTP’s, and departmental processes are continuously aligned with NCQA accreditation standards
- Respond to general inquiries and assist in resolution of administrative and operational issues. Manage staff data entry to maintain database/computerized credentialing system
- Maintain on-going participation in cross-training activities, ensuring appropriate staff training and coverage of incoming volume. Actively engage in addressing special projects as they arise, conducting preliminary research and follow-up, and tracking/monitoring to facilitate on-going reporting of project status. Provides valid feedback to the Credentialing Director on departmental issues and progress.
- Perform other functions as assigned.
COMPETENCIES
REQUIRED COMPETENCIES
1. Required Job Skills
- Excellent verbal and written communication skills
- Strong analytic skills and the ability to translate complicated data into useable information, including analysis of practice variation.
- Demonstrated organizational and project management skills to manage complex projects through effective planning, tracking, and resource allocation to meet business objectives and timelines.
- Ability to generate creative solutions, identify the best course of action and rapidly resolve complex issues/problems, strong leadership and management skills. Knowledge of methods used for improving employee performance/motivation.
- Skill in resolving employee/customer conflicts and complaints in a mutually satisfactory way
- Ability to communicate clearly with employees at all organizational levels, and across differing cultural backgrounds Maintains information in a confidential manner according to policy.
2. Required Professional Competencies
- N/A
3. Required Leadership Experience and Competencies
- N/A
PREFERRED COMPETENCIES
1. Preferred Job Skills
- Strong knowledge of Microsoft Office software (Outlook, Word, Excel, and Access, and PowerPoint) which expertise in Credentialing activities related to Medicare and Medicaid Programs strongly preferred.
2. Preferred Professional Competencies
- N/A
3. Preferred Leadership Experience and Competencies
- N/A
Our Commitment
BCBSAZ does not discriminate in hiring or employment on the basis of race, ethnicity, color, religion, sex, sexual orientation, gender identity, national origin, age, disability, protected veteran status or any other protected group.
Thank you for your interest in Blue Cross Blue Shield of Arizona. For more information on our company, see azblue.com. If interested in this position, please apply.
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