Summary

The Director of Credentialing and Quality Management is responsible for all aspects of the verification process for credentialing, quality, accreditation, and provider oversight.

The director develops and implements policies and procedures related to provider verifications and ensures that organization and providers are following organization, regulatory, accreditation and industry standards.

ESSENTIAL JOB FUNCTIONS

· Oversee credentialing activities, including areas of inquiry, budgeting, and related concerns.

· Chair the Credentialing Committee, aligning approval and documentation requirements for accreditation and preparing all materials for the Committee.

· Chair the Quality Provider Improvement Committee, and ensure minutes are taken along with proper documentation and materials.

· Maintain a written description of credentialing program which documents compliance with standards around:

o Credentialing

o Recredentialing

· Assessment of network providers and other licensed independent health care professionals

· Maintain positive interactions with providers and work with clinic and network in a cohesive, compliant manner.

· Sub-delegation of credentialing, as applicable

· Review activities, including establishing and maintaining a credentialing committee that meets on a regular basis.

· Identifies any compliance gaps to ensure the network maintains NCQA Accreditation and maintain key knowledge of accreditation process and procedures.

· Support and facilitate plan and accreditation audits, working with operational leaders and explaining process and requirements.

· Ensure NCQA standards are fully implemented, KPIs are developed, analyzed, and monitored on a regular basis.

· Provide regular quality and credentialing reports to the Executive team, the Compliance Officer and the Compliance Committee, notifying each of any critical path or issues.

· Identify and implement strategies for improvement as part of the quality improvement management, including a quality management program and working with clinical team to ensure high standards of quality compliance and oversight.

· Ensure compliance with federal, state, and contractual requirements regarding credentialing, licensure, and accreditation.

· Develop and Implement Policies and Procedures to meet requirements of organization, federal, state, and accrediting body requirements including but not limited to:

o Policies and procedures to ensure ongoing monitoring of practitioner sanctions, complaints, and quality issues between recredentialing cycles and ensure appropriate actions against practitioners are taken monitoring identifies occurrences of poor quality, including corrective action.

o Policies and procedures to ensure internal continuous quality improvement and protect credentialing information and practitioner data throughout the credentialing process.

o Credentialing policies and procedures describing/establishing:

§ The types of practitioners to credential and recredential.

§ The verification sources it uses.

§ The criteria for credentialing and recredentialing.

§ The process for making credentialing and recredentialing decisions.

§ The process for managing credentialing files that meet the organization’s established criteria.

§ The process for requiring that credentialing and recredentialing are conducted in a nondiscriminatory manner.

§ The process for notifying practitioners if information obtained during the organization’s credentialing process varies substantially from the information they provided to the organization.

§ The process for notifying practitioners of the credentialing and recredentialing decision within required time frame of the credentialing committee’s decision.

§ The Credentialing Directors direct responsibility and participation in the credentialing program.

§ The process for securing the confidentiality of all information obtained in the credentialing process, except as otherwise provided by law.

§ The process for confirming that listings in practitioner directories and other materials for members are consistent with credentialing data, including education, training, board certification and specialty.

· Develop and manage relationships with Providers. Perform outreach, monitoring and resolutions.

· Ensure Credentialing Committee is composed of active practitioners with the necessary expertise to render review of the files.

· In accordance with organizational and accreditation policies and procedures, determine and approve clean files as delegated by the Credentialing Committee.

· Ensure Committee actions and important notes are documented in committee minutes.

· Monitor improvement / corrective actions issued by the Committee, delegating payer or accreditation body.

PROFESSIONAL EXPERIENCE/QuALIFICATIONS

Requirements and Must Have Criteria

· A minimum of six (6) years health care focused roles with 7+ years in credentialing and provider enrollment, preferred in supplemental benefits and/or health plan exposure.

· Expertise with Microsoft Office software (Word, Access, Excel, PowerPoint), and experience with Credentialing systems.

· Previous Managed Care and/or Medicare Adbvantage, Medicaid experience strongly preferred.

· Excellent organizational skills, proven project management expertise.

· Strong verbal and written communication skills.

· Ability to work in a changing and evolving environment.

· Able to ‘get hands dirty’ by working on both tactical and strategic elements of the role, with a ‘start-up type’ mentality.

· Outstanding interpersonal skills, able to quickly establish a trusting rapport with individuals at all levels.

· Requisite poise, judgment, and trustworthiness to represent company to internal and external groups.

· Maintains information in a confidential manner according to policy.

EDUCATION

· Licensed Audiologist – Au.D. required

· Proper education to support 4 year degree and extended education specialized in hearing care.

· MBA preferred.Summary

The Director of Credentialing and Quality Management is responsible for all aspects of the verification process for credentialing, quality, accreditation, and provider oversight.

The director develops and implements policies and procedures related to provider verifications and ensures that organization and providers are following organization, regulatory, accreditation and industry standards.

ESSENTIAL JOB FUNCTIONS

· Oversee credentialing activities, including areas of inquiry, budgeting, and related concerns.

· Chair the Credentialing Committee, aligning approval and documentation requirements for accreditation and preparing all materials for the Committee.

· Chair the Quality Provider Improvement Committee, and ensure minutes are taken along with proper documentation and materials.

· Maintain a written description of credentialing program which documents compliance with standards around:

o Credentialing

o Recredentialing

· Assessment of network providers and other licensed independent health care professionals

· Maintain positive interactions with providers and work with clinic and network in a cohesive, compliant manner.

· Sub-delegation of credentialing, as applicable

· Review activities, including establishing and maintaining a credentialing committee that meets on a regular basis.

· Identifies any compliance gaps to ensure the network maintains NCQA Accreditation and maintain key knowledge of accreditation process and procedures.

· Support and facilitate plan and accreditation audits, working with operational leaders and explaining process and requirements.

· Ensure NCQA standards are fully implemented, KPIs are developed, analyzed, and monitored on a regular basis.

· Provide regular quality and credentialing reports to the Executive team, the Compliance Officer and the Compliance Committee, notifying each of any critical path or issues.

· Identify and implement strategies for improvement as part of the quality improvement management, including a quality management program and working with clinical team to ensure high standards of quality compliance and oversight.

· Ensure compliance with federal, state, and contractual requirements regarding credentialing, licensure, and accreditation.

· Develop and Implement Policies and Procedures to meet requirements of organization, federal, state, and accrediting body requirements including but not limited to:

o Policies and procedures to ensure ongoing monitoring of practitioner sanctions, complaints, and quality issues between recredentialing cycles and ensure appropriate actions against practitioners are taken monitoring identifies occurrences of poor quality, including corrective action.

o Policies and procedures to ensure internal continuous quality improvement and protect credentialing information and practitioner data throughout the credentialing process.

o Credentialing policies and procedures describing/establishing:

The types of practitioners to credential and recredential.

The verification sources it uses.

The criteria for credentialing and recredentialing.

The process for making credentialing and recredentialing decisions.

The process for managing credentialing files that meet the organization’s established criteria.

The process for requiring that credentialing and recredentialing are conducted in a nondiscriminatory manner.

The process for notifying practitioners if information obtained during the organization’s credentialing process varies substantially from the information they provided to the organization.

The process for notifying practitioners of the credentialing and recredentialing decision within required time frame of the credentialing committee’s decision.

The Credentialing Directors direct responsibility and participation in the credentialing program.

The process for securing the confidentiality of all information obtained in the credentialing process, except as otherwise provided by law.

The process for confirming that listings in practitioner directories and other materials for members are consistent with credentialing data, including education, training, board certification and specialty.

· Develop and manage relationships with Providers. Perform outreach, monitoring and resolutions.

· Ensure Credentialing Committee is composed of active practitioners with the necessary expertise to render review of the files.

· In accordance with organizational and accreditation policies and procedures, determine and approve clean files as delegated by the Credentialing Committee.

· Ensure Committee actions and important notes are documented in committee minutes.

· Monitor improvement / corrective actions issued by the Committee, delegating payer or accreditation body.

PROFESSIONAL EXPERIENCE/QuALIFICATIONS

Requirements and Must Have Criteria

· A minimum of six (6) years health care focused roles with 7+ years in credentialing and provider enrollment, preferred in supplemental benefits and/or health plan exposure.

· Expertise with Microsoft Office software (Word, Access, Excel, PowerPoint), and experience with Credentialing systems.

· Previous Managed Care and/or Medicare Adbvantage, Medicaid experience strongly preferred.

· Excellent organizational skills, proven project management expertise.

· Strong verbal and written communication skills.

· Ability to work in a changing and evolving environment.

· Able to ‘get hands dirty’ by working on both tactical and strategic elements of the role, with a ‘start-up type’ mentality.

· Outstanding interpersonal skills, able to quickly establish a trusting rapport with individuals at all levels.

· Requisite poise, judgment, and trustworthiness to represent company to internal and external groups.

· Maintains information in a confidential manner according to policy.

EDUCATION

· Licensed Audiologist – Au.D. required

· Proper education to support 4 year degree and extended education specialized in hearing care.

· MBA preferred.

Job Types: Full-time, Part-time

Pay: $44,785.40 - $150,000.00 per year

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Schedule:

• 8 hour shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Experience:

• Audiology: 5 years (Required)
• Microsoft Word: 1 year (Preferred)

Work Location: Hybrid remote in Clinton Township, MI 48035

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