Director Credentialing and Payer Enrollment

***This role is remote.

Dignity Health Medical Foundation, established in 1993, is a California nonprofit public benefit corporation with care centers throughout California. Dignity Health Medical Foundation is an affiliate of Dignity Health - one of the largest health systems in the nation - with hospitals and care centers in California, Arizona and Nevada. Today Dignity Health Medical Foundation works hand-in-hand with physicians and providers throughout California to provide comprehensive health care services to the many communities we serve. As Dignity Health Medical Foundation continues to grow and establish new premier care centers we provide increasing support and investment in the latest technologies, finest physicians and state-of-the-art medical facilities. We strive to create purposeful work settings where staff can provide great care while advancing in knowledge and experience through challenging work assignments and stimulating relationships. Our staff is well-trained and highly skilled qualities that are vital to maintaining excellence in care and service.

***This role is remote.

Working in a dynamic and fast-paced environment, the Director is responsible for managing all aspects of our ambulatory Credentialing and Payer Enrollment programs, supporting 200+ clinic locations and 1800 clinicians serving 13 geographic markets across the state of California. Our credentialing program meets or exceeds NCQA, URAC and Medicare standards and the Director is charged with maintaining those high standards, along with our credentialing delegation agreements. We work collaboratively, and in partnership with, our medical groups, recruiters and the hospitals to ensure a smooth onboarding process for our applicants. 

Position Summary:

The Director, Credentialing and Payer Enrollment is responsible and accountable for the planning, direction, control and evaluation of the Credentialing Department and the Payer Enrollment Department on behalf of Dignity Health Medical Foundation (DHMF), the aligned Medical Groups, non-DHMF clinics purchasing services, other DHMF and Dignity Health initiatives (e.g. new business ventures), as well as the ongoing rapid provider mergers and acquisition Credentialing and enrollment.
The Director is the liaison to DHMF senior leadership, internal and external legal counsel, corporate real estate, risk management, as well as Medical Group physician leadership. The Director not only facilities and participates on committees (e.g. Malpractice Underwriting Committee, DHMF Credentialing Committee, etc.), but is a subject matter expert for other standing committees as it relates to NCQA standards, Medicare Advantage standards, government enrollment regulatory requirements, health plan delegation requirements, regulatory interpretation and research. The Director is expected to stay current on health plan requirements, accreditation standards, federal and state related Credentialing and enrollment changes, participate in workgroups and focus groups at the national level, analyze/predict the potential impact on the organization and develop, implement and document processes to support any changes.
The Director is responsible for the operational and financial management of the Credentialing Department and the Payer Enrollment Department. The Director is responsible to standardize processes, reduce duplication, ensure efficiency, and deliver a service that can meet not only the needs of the Medical Groups and DHMF, but remain compliant with regulatory and health plan mandated requirements.
In the absence of a Manager, Credentialing, and Payer Enrollment or other department supervisory role, the Director will assume those job functions. The Director will manage the daily operational needs, services and functions related to credentialing, recredentialing, privileging, ongoing professional/sanction monitoring, professional liability insurance coverage, incentive program registration and Payer Enrollment processes.
The Director is responsible to ensure that all new providers are credentialed, recredentialed and privileged in a timely manner accordance with regulations and accreditation standards and are properly enrolled with all commercial and government payer contracts and associated programs.
The Director represents DHMF interests to all types of external organizations and Payers including health plans, accrediting bodies, hospitals, federal and state government agencies/programs, private healthcare insurers, workers compensation insurers, etc.
The Director acts as a liaison with Medical Group leadership (ensuring provider cooperation with the Credentialing and privileging processes and understanding of financial ramifications related to delayed or incorrect enrollment), Legal Counsel (ROI related to delegated credentialing, appeals and government-caused payment delays) and Finance (ongoing monitoring of accounts receivable days, average time to full enrollment, accuracy and integrity of enrollment related data).
The Director is also responsible to develop, supervise and manage various Credentialing and Payer Enrollment related initiatives and has direct supervision for the Credentialing Coordinators, Credentialing Specialists, Enrollment Analysts, and Enrollment Coordinators.

Minimum Qualifications:

- Minimum of 7 years in management of credentialing, Payer Enrollment, peer review, quality improvement, quality management and health plan delegation agreements required.
- Certified Professional in Medical Services Management (CPMSM) and Certified Provider Credentialing Specialist (CPCS) and BA/BS degree in Business Administration, Health Care Administration required. The following certifications collectively may be used in lieu of BA/BS: (1) Certified Professional in Healthcare Quality (CPHQ); (2) Certified Professional in Medical Services Management (CPMSM); and (3) Certified Provider Credentialing Specialist (CPCS), or equivalent applicable years of experience
- Project management experience and excellent written and communication skills required. Ability to organize and prioritize multiple project and competing deadlines in an effect manner required.
- Exceptional computer skills including Word and Excel required. Database management knowledge required.

Preferred Qualifications:

- Greater than 12 years in management of credentialing, Payer Enrollment, peer review, quality improvement, quality management and health plan delegation agreements preferred.
- Certified Professional in Healthcare Quality (CPHQ) preferred.

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