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Schedule/Status:

Full Time

Standard Hours/Week:

40

General Description:

Under the supervision of the Florida Health Executive Director, the Credentialing Manager is responsible for the development and implementation of a Credentialing Program for the Florida Health network of providers to meet NCQA credentialing and re-credentialing certification requirements. Create credentialing policies and procedures to be compliant with payer credentialing polices and compliant with state and federal laws.

Key Responsibilities:

Responsible for the development and oversight of a Florida Health Credentialing Program. Responsible for the development of all credentialing and re-credentialing policies and procedures in adherence with NCQH, JCAHO, state and federal law and payer requirements and to include the creation and maintenance of a credentialing and re-credentialing verification process.

Implementation of a provider credentialing appeals process and provider site audit tools. Directly responsible for coordinating the credentialing committee and credentialing minutes. Interpret, and explain all regulatory guidelines including FH, NBMS and PMC staff by laws, fair hearing, plan rules and regulation and policies. Work in conjunction with Quality Director to assure that the Quality program policies and procedures meet payer requirements for Site Visits, Monitoring sanctions, complaints and Quality issues.

Responsible for the credentialing process to include coordinating, monitoring and maintaining credentialing and re-credentialing with non-delegated payers. Maintain Provider Data File - Maintain systems to identify, track and disseminate to appropriate care team members. Develop communication and data work flow processes.

Identify and review and implement Credentialing Software to support delegated credentialing process. Responsible for the accuracy and integrity of the credentialing database system and for data entry performed by personnel. Ensure maintenance of licensed medical providers credentialing files for accuracy and compliance.

Demonstrate effective leadership skills and coordination of intra-department activities and integration. Assure ongoing development and implementation of policies and procedures that guide and support the provision of services.

Work with Medical Staff leadership and hospital clinical staff for the approval and ongoing review of credentialed providers.

Performs similar or related duties as assigned.

Requirements:

Formal Education:

Associate’s Degree, and/or other two year college equivalent: Healthcare, Business, Computer Science .

Work Experience:

5 years + credentialing experience

Required Licenses, Certifications, Registrations:

NA