Credentialing Supervisor

The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

Summary

Under general supervision provides oversight and coordinates the daily operations of the Credentialing unit to ensure credentialing and recredentialing activities are conducted timely and consistent with HPSJ guidelines and contractual and regulatory standards. Work is occasionally varied and minimally to moderately complex and requires a limited to moderate degree of discretion and independent judgment.

Supervises

• Credentialing Team
  
  

Essential Functions

• Plans and assigns work; monitors workload to ensure compliance with HPSJ, regulatory and contractual standards; makes timely and effective adjustments.
• Sets up and maintains data collection and reporting systems and oversees data entry activities.
• Assists in the development of and implements and maintains credentialing department guidelines, policies and procedures; communicates changes in a timely and effective manner.
• Performs credentialing and recredentialing activities, including preparation of review of documentation and verifications; resolves or facilitates resolution of the most complex credentialing issues.
• Submits and oversees the submission of completed profiles to Medical Director and the Peer Review/Credentialing Committee.
• Notifies providers of outcomes of credentialing process; notifies appropriate internal and external stakeholders of provider status changes according to established internal timelines.
• Identifies training needs and opportunities; develops and delivers routine and ad hoc department training.
• Prepares for and participates in regulatory audits; gathers information, prepares team, maintains required reports, develops and monitors timely and effective corrective actions plans.
• Assists the Quality Improvement Department with facility site reviews (FSRs) and maintains FSR aggregate.
• Compiles, develops and submits or oversees the compilation, development and submission of internal and external reports.
• Coordinates the Peer Review/Credentialing Committee meeting including preparing and distributing meeting packets, reviewing minutes and following up on action items.
• Represents the credentialing team/department in internal/external meetings.
• Collaborates with interdepartmental units to establish and improve workflow and processes identifies issues and opportunities; resolves issues or makes recommendations as required.
• Assists with revisions and enhancements of credentialing software and other tools.
• Promotes and maintains an environment that supports HPSJ’s strategy, vision, mission and values.
• Hires, supervises and retains competent staff.
  
  

Non-Essential Functions

• Other duties as required.
  
  

Required

Education and Experience

• Associate degree; and
• At least three years as a Credentialing Specialist in a Medi-Cal managed care environment; or
• Equivalent combination of education and experience.
  
  

Preferred

• Experience in credentialing for Medicare
  
  

Licenses, Certifications

Required

• Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.
  
  

Preferred

• None.
  
  

Required

Knowledge, Skills, Abilities and Competencies

• In-depth knowledge of NCQA and Medi-Cal credentialing standards.
• In-depth knowledge of the principles of managed care.
• In-depth knowledge of and ability to use credentialing software systems.
• In-depth knowledge of record keeping principles and techniques.
• Basic knowledge of audit processes, and the ability to effectively implement and maintain them.
• Basic knowledge of data analysis and communication/reporting tools and techniques, with ability to perform analysis and resolve problems , and recognize and act on trends.
• Strong oral and written communication skills with the ability to communicate professionally to diverse individuals inside and outside of HPSJ, effectively explain complex information, and conduct presentations.
• Strong interpersonal skills with the ability to establish and maintain effective working relationships with individuals at all levels inside and outside of HPSJ.
• Ability to develop, implement and maintain processes, procedures and other guidelines.
• Strong collaboration skills, including but not limited to the ability to create and foster a collaborative work environment, and organize people and resources to solve problems and identify opportunities.
• Strong facilitation, problem solving and conflict resolution skills, with the ability to use tact and diplomacy to diffuse emotional situations.
• Strong planning and organizational skills with the ability to effectively prioritize multiple tasks.
• Ability to develop and deliver relevant and effective training and supporting materials.
• Decision quality: Makes good and timely decisions that keep the organization moving forward.
• Action oriented: Takes on new opportunities and tough challenges with a sense of urgency, high energy and enthusiasm.
• Resourcefulness: Secures and deploys resources effectively and efficiently; organizes people and resources to solve problems and identify opportunities.
• Directs work: Provides direction, delegates and removes obstacles to get work done.
• Plans and aligns: Plans and prioritizes work to meet commitments aligned with organization goals.
• Optimizes work processes: Knows the most effective and efficient process to get things done, with a focus on continuous improvement; can develop, implement and maintain processes.
• Ensures accountability: Holds self and others accountable to meet commitments.
• Drives results: Consistently achieves results, even under tough circumstances.
• Organizational savvy: Maneuvers comfortably through complex policy, process and people- related organizational dynamics.
• Being resilient: Rebounds from setbacks and adversity when facing difficult situations.
• Courage: Steps up to address difficult issues, says what needs to be said.
• Situational adaptability: Adapts approach and demeanor in real time to match the shifting demands of different situations.
• Demonstrated ability to articulate and support HPSJ’s vision, mission, values and strategy, integrate into management practices, and foster their manifestation among staff.
• Strong supervisory and leadership skills, with the ability to supervise staff in a manner that maximizes employee performance and business results.
• Strong mathematics skills, including the ability to calculate ratios, perform simple algebra and statistical formulas.
• Intermediate skills in Windows, Outlook, Word and PowerPoint.
• Intermediate skills in Word and Excel, including the ability to create formulas and pivot tables.
• Ability to speak and be understood in English.
• Ability to handle confidential information with appropriate discretion.
  
  

Preferred

• Knowledge of Medicare credentialing requirements.
  
  

Physical Demands

• Frequent sitting, standing and walking.
• Frequent repetitive motion – keyboarding and writing.
• Frequent talking and listening in person and over the phone.
• Occasional talking and listening to groups.
• Occasional handling of materials up to 10 lbs.
• Close up and distance vision requirements.
• Frequent public contact.
• Occasional travel.
  
  

Emotional/Psychological Demands

• Ability to cope with: frequent interruptions; working under pressure; negative responses; frequent public contact.
  
  

Work Environment

Open office environment; moderate temperatures; moderate noise levels.

We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.

HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.

Important Notice : This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.