Centura Health Physician Group (CHPG) offers providers a true opportunity to live their calling to care while experiencing the support of a built-in comprehensive network, vast resources, professional growth, trusted leadership, generous benefits and an amazing quality of life with locations that span Colorado and into Western Kansas. CHPG is proud to connect providers and consumers through state-of-the-art technology, clinical resources and professional expertise to help people live healthier. Our coordinated services represent a full continuum of care – from preventive and early diagnoses to leading-edge treatment and life-saving critical care. CHPG’s ability to deliver better health care value is the direct result of combining the best clinical tools, shared resources and medical expertise with a patient-centered approach that emphasizes Centura Health’s mission and commitment to quality, compassion and service.
Occasional travel to other sites to meet the needs of the clinic may be required.
This leadership position is responsible for the direct leadership of the Payer Credentialing staff. This position provides direct management of associates for hiring, training, and administering corrective action in order to maintain a quality service. Provides operational management of the department including understanding, monitoring, and improving work-flow, processes, day to day problem resolution, and troubleshooting. Participates in decision making concerning policies and procedures. Responsible for administrative work in directing and coordinating a comprehensive specialized credentialing program to assure compliance with the payer credentialing requirements and delegated carrier agreements and NCQA requirements that are built into our policies and procedures. Work includes responsibility for the coordination of all operational aspects related to delegated credentialing, non-delegated and governmental credentialing, including organizing and assisting programs required for establishing procedures for payer credentialing of physicians / allied health professionals. Complete all required governmental forms for Medicare and Medicaid timely and follow through till completion and assigned numbers and effective dates. Complete tracking tool for credentialing processes and effective dates. Assist with completion and updates of Council for Affordable Quality Healthcare (CAQH) profiles. Build relationships with commercial and governmental carriers to follow-up on outstanding items, through obtaining assigned effective dates or confirmation of correct provider load. Assist in pulling required reporting from CACTUS software, and follow-up with physicians/allied health professionals to assure accuracy and timeliness of information submitted to carriers. Assist with ongoing improvements and development of PE delegated credentialing policy and procedures. Understand and engage in National Committee for Quality Assurance (NCQA) requirements, to effectively work with our delegated commercial carriers.
Work is reviewed by the Supervisor of the department through reports, conferences and adherence to management guidelines and regulations.
High School Diploma
AA or business courses strongly preferred, (without an Associates degree, an additional 2-4 years direct experience working experience of commercial payer credentialing)
Work Experience Requirements
5 years of healthcare-related physician/allied health professionals credentialing experience
Must have strong organizational, written, verbal, problem solving, and relationship building skills.
Ability to work independently and multi-task
CACTUS software experience preferred/recommended
Positon Duties (essential functions, include % of time)
SUPERVISORY JOB DUTIES-60%
Assists and performs the PFD process with all direct reports.
Assists and performs maintenance of Kronos for attendance purposes
Coordinates quality activities within the department by assisting in implementation and providing oversight of quality policies, procedures, and monitoring of results and facilitating corrective actions. Participates in quality improvement projects.
Partners with the various departments and facilities throughout the system to achieve resolution.
Researches and resolves issues to meet customer needs (departments, facilities, clinics, payers, etc).
Demonstrates good time management skills.
Supervises the daily activities and time management of staff by effective communication, training, guidance, and direction .
Assures staff accomplishes all assigned tasks in an efficient and timely manner
Assists in interviewing and hiring of new staff.
Responsible for the development of department specific procedures, performs special projects, and miscellaneous/administrative
duties as assigned. Keeps Associate Administrator and Administrator informed of activities and decisions made within department.
PHYSICIAN CREDENTIALING ·20%
Assist in the organizing and directing of a comprehensive and specialized credentialing program to assure continued delegated credentialing by payers and other regulatory organizations.
Interpret, explain and follow all regulatory guidelines, including NCQA guidelines and payer credentialing guidelines.
Maintain systems to identify (and disseminate to others) delegated physicians/allied health professionals, non-delegated but credentialed physicians/allied health professionals, Prepare and maintain other related records and reports that identify the initial application, reappointment and expired profiles and / or files.
Responsible for the credentialing process of physicians / allied health professionals.
Complete government applications for physicians / allied health professionals (Medicare, Medicaid, Tricare).
CREDENTIALING COMPLIANCE WITH POLICIES AND PROCEDURES- 10%
Reviews files of physicians and allied health professionals to ensure appropriate documentation is present
Assist Supervisor with Med Staff offices and CVO to monitor and report on adherence to the delegated credentialing policies.
Demonstrates effective communication skills and assist Supervisor of inter-department communication to support compliance with payers.
Assists in writing and implementation of new policies and procedures.
REPORTS - 5%
Prepares reports for Director that encompasses details of adds, deletes and terminations of individual physicians and allied health professionals by payer.
Prepares spreadsheets that identify the status of government applications for each individual physician / allied health professional as well as the status of the practice NPI.
Prepare monthly expirable reports and work with practices to update materials.
Prepare other reports as requested by Director.
CRITICAL THINKING SKILLS - 5%
Maintains a customer friendly rapport with peers and internal customers
Communicates appropriately and professionally with peers
Reports any non-compliance of the delegated process immediately to Associate Administrator.
Sedentary work -(prolonged periods of sitting and exert up to 101bs force occasionally)
Important notification to applicants as of Nov. 20, 2014: Effective Jan. 1, 2015, Centura Health will no longer hire tobacco users in Colorado and Kansas. The change to our policy does not apply to associates hired on or before Dec. 31, 2014. Centura Health is an Equal Opportunity Employer, M/F/D/V.
Find your ideal career at Centura Health! With 16 hospitals, physician clinics, hospice services, home care and senior living communities, Centura Health's vast network of care spans Colorado and Western Kansas so you can experience a balanced lifestyle and enjoy a fulfilling career anywhere you want to work, live and play in Colorado. From the fast pace of a Denver-area Level 1 Trauma Center to a... smaller rural or mountain hospital – we proudly offer a more diverse range of work settings and locations than any other health care employer in the state. Centura is an equal opportunity employer.