Job Description

THIS ROLE IS A REMOTE POSITION AND CAN BE PERFORMED ANYWHERE IN THE UNITED STATES.

ROLE SUMMARY:

AllyAlign Health (www.allyalign.com) is a rapidly growing organization focused on revolutionizing the long-term healthcare ecosystem for the benefit of our members, provider and payer partners. Our unique approach to managing care delivery and proactively partnering with healthcare providers has enabled us to achieve industry leading health outcomes for our members. AllyAlign Health has partnered with several Nursing Home companies to form Institutional Special Needs Plans (I-SNPS), which are a form of Medicare Advantage Plans.

In this model, AllyAlign is responsible for administering the health plans, providing shared services such as member enrollment, call center, claims processing, authorization processing, financial services, compliance services and grievance and appeals administration. AllyAlign has grown very aggressively and is working to expand our operational capacity and capability.

AllyAlign Health is looking for a qualified candidate to lead our Credentialing process, as a Provider Network Credentialing lead. This role reports to the Director of Provider Network Management.

JOB SUMMARY:

This role will oversee all aspects of the credentialing process according to CMS, NCQA, state and insurance standards. This role is a critical part of AllyAlign's operations and essential to our ability to onboard providers, as well as our ability to expand our services to new geographical service areas. Utilize your expertise and ideas to shape the department and implement new processes as the team and organization expands.

RESPONSIBILITIES:

• Monitoring and Management of Credentialing Vendor Organization (CVO) performance to contracted standards.
• Oversee CVO Queue Management, Provider File Maintenance, Quality, Production and Timeliness of credentialing standards are met.
• Define and support the development and maintenance of the AAH Provider Network Credentialing Policies and Procedures ensuring required process implementation and operational performance to defined methods and standards.
• Keep management, plan Executive Directors and Account Managers informed of department issues, stakeholder failure to follow defined procedures and submission standards in work submitted, quality of vendor work and systems performance and recommended efficiencies to improve cost effectiveness, timeliness, and quality.
• Work with vendors, peers and AAH management in enforcing a systematic approach to credentialing workflow.
• Make and oversee credentialing system updates ensuring provider contracted and credentialing status is properly reflected in the Provider Data Management tool, Provider360.
• Provide monthly written assessment of vendor performance based on defined, objective criteria.
• Ensure provider, facility and delegated entity credentialing approval, denial, follow up and request letters are tracked, generated, and delivered timely for distribution.
• Monitor the Provider Data Management system and CVO processing system integration, implementation, and operations, assisting the data team with information and process updates as needed.
• Research provider credentialing issues and implement new processes to prevent re-occurrence.
• Maintain Credentialing Committee documentation, present provider issues at committee and oversee the committee agenda.
• Oversee delegation standards, ensure delegated groups maintain compliance and notify impacted areas of delegation approvals/denials.
• Communicate delegation & credentialing status to providers and ensure proper updates are made to the provider management system.
• Review CVO monitoring, outreach, credentialing, and failure reports on an ongoing basis, ensuring proper communication is sent to providers as well as impacted business areas when a provider's credentialing status changes.
• Perform email, written and verbal outreach to providers to obtain missing or updated documentation needed for credentialing or recredentialing of providers.
• Review and transmit weekly facility & physician credentialing applications to CVO and perform QA on outgoing and incoming files to ensure all providers are successfully transmitted to the CVO platform.
• Train new AAH staff, Medical Directors, and plan partners on AAHs credentialing process and the CVO platform as needed.

KNOWLEDGE & SKILLS REQUIRED:

• Minimum 7 years within a Managed Care environment and payor organization
• Bachelor's Degree or an equivalent combination of education and/ or healthcare experience
• Minimum of 5 years with provider contracting and credentialing processes.
• Comprehensive understanding of facility and physician credentialing requirements as published by CMS and State Medicaid agencies, where applicable
• Experience of performance managing 3rd party vendor partners.
• Excellent communication skills and ability to engage at all levels of an organization and with client partners.
• Microsoft Office Suite

BENEFITS:

• Market competitive salary
• Flexible PTO
• 9 Paid Holidays per Year (7 fixed and 2 floating)
• Medical Insurance
• Dental Insurance benefits
• Vision Insurance benefits
• Health Savings Account contributions if you elect to participate in our Medical Insurance plan
• Long-Term Disability / Short-Term Disability and Life Insurance
• 401K Plan