Supervisor, Credentialing Services (PMG)

Supervises team to review and request primary source information and verifications. Proactively identifies, suggests improvements to, and provides resolutions for complex gaps in vendor relationships. Serves as an escalation point of contact for external queries regarding practitioner status. Evaluates applications and supports highly complex documents. Guides team to conduct improvements to credentialing and privileging processes. Guides and supervises team to evaluate complex practitioner sanctions. Participates in surveys and audits of credentialing entities. Facilitates and implements strategic initiatives for cost-effective due process. Identifies and provides leadership to resolve adverse actions/issues. Leads and evaluates audits of data between different departments. Conducts and supervises the facilitation, orientation, and training of newly appointed physician leaders. Develops highly complex informational documents. Maintains working relationships with key stakeholders. Maintains awareness of current policy and climate interactions. Guides team to facilitate meetings with leadership to develop on-boarding processes. Supervises team to process complex provider enrollment information. Ensures team completes communications of relevant information to appropriate parties. Supervises team to enact control of data systems and applications. Supervises team to ensure credentialing data analyses. Reviews multiple types of database structures and data. Communicates status, leads development of corrective action plans, and collaborates with relevant teams to conduct audits and site visits.

• Recommends developmental opportunities for others; builds collaborative, cross-functional relationships. Solicits and acts on performance feedback; provides team members with feedback; and mentors and coaches to drive performance improvement. Pursues professional growth; provides training and development to talent for growth opportunities; supports execution of performance management guidelines and expectations. Implements, adapts, and stays up to date with organizational change, challenges, feedback, best practices and processes. Fosters open dialogue, supports, mentors, engages, and motivates team members on collaboration. Delegates tasks and decisions as appropriate; provides appropriate support, guidance and scope.


• Supervises and coordinates daily activities of designated work team or unit by monitoring the execution and completion of tactical action items and work assignments; ensures all policies and procedures are followed. Aligns team efforts and standards, and measures progress in achieving results; determines and carries out processes and methodologies; resolves escalated issues as appropriate. Develops work plans to meet business priorities and deadlines; coordinates, obtains and distributes resources. Removes obstacles that impact performance; identifies and recommends improvement opportunities; influences teams to execute in alignment with operational objectives.


• Manages credentialing and privileging maintenance and management by: guiding teams to implement requirements when completing evaluation of applications and supporting documents for completeness and to determine applicants initial eligibility for membership/participation; serving as an escalation point of contact for practitioner during application process, providing timely updates and additional information as requested; planning and scheduling team to prepare and complete complex documents (e.g., Board Reports, Delegation reports) related to practitioner-specific data for presentations to decision-making bodies (e.g., committees); guiding teams to implement and suggest improvements to credentialing and privileging processes for all practitioners/providers; and gathering documentation needed to influence decisions on the enforcement and development of policies/procedures for regulations and auditing processes.


• Manages data management and analyses by: supervising team to ensure efficient file completion, conduct privileging analyses, and verify privileging to the appropriate specialty/facility, based on data; and supervising team to leverage and independently leveraging complex tools and policies to support knowledge management, record-keeping, and internal and external communication.


• Applies and ensures control and application of data systems by: supervising and reviewing the team to maintain data structures, system functions, creations of workflows, portal management and coordinating the access and controls of data; leading teams to engage in auditing, assessing, procuring, implementing, effectively utilizing, and maintaining practitioner/provider credentialing and delegated processes and information systems (e.g., files, reports, minutes, databases) as outlined; and reviewing, evaluating, and escalating improvements to processes (e.g., electronic board memos) to ensure compliance.


• Conducts database management by: reviewing multiple types of structures and data within a computerized data base of physician data for use in the credentialling and appointment process in alignment with department guidelines.


• Engages in delegations by: communicating status of, assisting in development of corrective action plans, and identifying gaps or breach of delegated credentialing agreements in alignment with developed strategy for potential and existing delegates; aiding the facilitation of mutual agreement and amendments as needed, obtaining signatures, and maintaining Delegated Credentialing Agreements; scheduling and conducting pre-assessment, annual site visits, and/or electronic assessments to validate credentialing information; and collaborating with State Standardization and Audit teams (e.g., Washington Credentialing Standardization Group Shared Delegation Audit Team, ICE) on shared delegation audits.


• Leads primary source verification and management by: supervising team to engage in requesting, obtaining, and reviewing information from primary source verifications and ensuring accuracy in evaluation of applications and provided sources for alignment; maintaining the primary source vendor/relationships to ensure accessibility to information and beginning to resolve issues with vendor information; planning and scheduling the continuous process of, providing resources for, and conducting the review process of applications, primary source verifications, and sources provided to identify potential discrepancies, recognize adverse information, and meet organizational objectives and timelines; leading team to engage in verifying and documenting expirables using acceptable verification sources to ensure compliance with accreditation and regulatory standards; and serving as escalation point for external queries regarding practitioners status, ensuring responses occur in a timely matter.


• Manages the provider enrollment process by: supervising team, reviewing for accuracy, and conducting moderately complex detailed and thorough review of the information used to submit the enrollment applications; supervising team to prepare and submit timely data and applications to the contracted and government payors in a manner commensurate with their expectations, policies and accreditation standards; and ensuring team completes communication of enrollment status to all stakeholders in a clear and timely manner.


• Ensures quality assurance, improvement, and resolution by: guiding and supervising team to obtain and evaluate practitioner sanctions, complaints, and adverse data to ensure compliance; supervising and evaluating ongoing assessments of governing documents (e.g., bylaws/rules and regulations/policies and procedures) to ensure continuous compliance; maintaining collaborative efforts and participating in surveys and audits of credentialing entities (e.g., CMOs, delegates and health plans for NCQA); guiding team on techniques and strategies to facilitate efficient and cost-effective due process that complies with internal fair hearing and appeals policies and external legal and regulatory requirements; evaluating team identification, resolving, escalating as needed, and responding to adverse actions/issues (e.g., sanctions and complaints) taken against a practitioner/provider in accordance with applicable law and contractual requirements to the necessary parties; and guiding team to audit and reconcile data between different departments for consistency and monitoring credentialing and contracting.


• Leads training and regulatory awareness by: guiding team during and independently facilitating orientation and training for newly appointed physician leaders for effective management of their departments credentialing, proctoring, privileging and reappointment processes; supervising team during and independently developing complex informational/educational documents (newsletters, memos) to communicate critical information regarding organizational programs and policies; supervising the development and cultivation of working relationships with key stakeholders, both internal and external, to ensure appropriate awareness of key issues and decision-making; guiding team to facilitate meeting with leadership to develop on-boarding processes (orientation, training activities) to assist practitioners/providers and to meet education requirements; updating applicable governing documents (bylaws, rules and regulations/policies and procedures) that support and direct organizational practices and ensure compliance; and maintaining awareness of current internal policies and external regulations, and legislation.