The Director of Credentialing oversees the operations of the Medimore, Inc which includes the UnityPoint Health System Centralized Verification Office (CVO) and Physician Hospital Organization provider network. This position will oversee all credentialing and payor enrollment for all employed practitioners of UnityPoint Health and ACO contracted providers, ensuring compliance with the appropriate accrediting and regulatory agencies. Oversight of the day-to-day management of the overall CVO credentialing process and database management. In addition, this position is responsible for the development and maintenance of the Medimore, Inc. provider network, including maintaining the network administrative policies and procedures, ensuring network providers meets payor credentialing requirements, NCQA or other agency standards, all provider communication necessary for the network and payor compliance, working with affiliates and Senior Leadership to ensure the needs of the network are met, including the UnityPoint Health Employee Health Plan. This position will maintain the relationships with the hospital medical staff offices and providers, serving as a provider advocate when representing provider issues to payor.
Leadership and Management
Responsible for the development and implementation of the strategy to advance the Medimore, Inc CVO and Physician Hospital organization provider network.
Develop and implement processes to achieve strategic initiatives, priorities and goals of the department. Ensure initiatives align with the overall mission and vision for Payor Innovations, UnityPoint Health and affiliates.
Drive execution and transformational change within the teams to ensure effective, efficient, sustainable, compliant and leading-edge operations to contribute to the financial success of UnityPoint Health.
Build and maintain relationships with stakeholders, regions and team members creating an environment where UnityPoint Health values are continuously exceeded.
Oversee new systems, products and business implementations for the department.
Assess organizational strengths and weaknesses to recommend enhanced operational models.
Lead standardizing, creating and sustaining a common culture and high performing operation aligned with UnityPoint Health-System Services priorities and serving the needs of our regions and patients.
Motivate, facilitate, mentor, and coach team to deliver high quality, cost effective services. Facilitates the ongoing learning, well-being, professional satisfaction and development of staff through training, work assignments, increased responsibility, and mentoring.
Evaluate performance of direct reports and their teams. Make recommendations for personnel actions and motivate employees to achieve peak productivity and performance.
Responsible establishing process to ensure the education, training and consultations across UnityPoint Health with regards to credentialing practices and services; ensuring appropriate team members are able to prepare and conduct credentialing orientations and provides updates as appropriate on new policies and procedures.
Oversees and provides direction to department leaders in their daily oversight of work allocation, training, promotion, enforcement of internal procedures and controls, and problem resolution; evaluates performance and makes recommendations for personnel actions; motivates employees to achieve peak productivity and performance.
Presents data, strategies, and progress towards goals in various governance management forums.
Researches tools and solutions to advance, support and optimize the CVO service delivery.
Develop and ensures metrics, goals, and projects are executed, tracked and accomplished for the CVO team.
Oversee the development procedures and policies to for operation of CVO department, process and team members. Improve and promote quality and performance improvement. This includes knowledge of best practices, prompt identification and resolution of staff concerns or problems, providing prompt service recovery and soliciting customer feedback to improve care and service
Ensure the organization maintains a high level of integrity through comprehensive understanding of CVO and Physician Hospital Organization
Credentialing Verification Organization
Leads the development, implementation and maintenance of the standardize practitioner credentialing process for UnityPoint Health functioning as the primary CVO credentials for internal and external inquiries.
Responsible for ensuring the credentialing process:
Is in compliance with oversight agencies, federal and state laws, and organizational policies,
Is efficient and maximizes the use of the credentialing application software
Effectively manages and coordinates the expirables to ensure all clinical provider licenses and certificates remain current, ensuring appropriate notification prior to expiration.
Meets each Hospital Medical Staff Office credentialing requirements, including entity-specific medical staff bylaws, rules and regulations, and policies and procedures, and hospital accrediting organization requirements.
Responsible for UnityPoint Health Practitioner enrollment with non-delegated payors.
Direct and monitor processes related to accurate and timely functions of the CVO, within or better than established departmental and industry benchmarks.
Represents the CVO through presentations, communications and other mediums to routinely interact with internal and external customers
Responsible for ensuring that the credentialing data is accurate and available for other systems to utilize as their source of truth. i.e. the ACO, physician finder, My Nurse
Physician Hospital Organization
Oversees the development and maintenance of the Medimore provider network, including processing provider interest profiles for network participation, and manage the provider contracting efforts.
Responsible for assisting network provider issue resolution with payors.
Oversight of credentialing related accounts receivable in coordination with Revenue Cycle department.
Ensure contract compliance with payor/provider Bylaws and Articles of Incorporation.
Secure and maintain credentialing delegation agreements with payors.
Monitor, maintain, document, distribute all credentialing/re-credentialing standard changes to Medimore and delegated MSO staff.
Coordinate and conduct activities related to payor audits, ensuring timely implementation of any corrective action plan.
Coordinate and conduct activities for Medimore, Inc. credentialing committee/VPMA meetings.
Facilitate standardization and distribution of provider materials distributed by payors.
Budget and Planning
Develop department budgets for staffing, operations, and capital resources. Manage actual costs to budget and proactively address any unfavorable budget variances.
Evaluating key financial, budgetary, and other metrics related to supply chain effectiveness
Determine, monitor and report on the department’s budget.
Provides information on forecasts, trends, or other conditions that may affect operations or budget planning.
Participates in the development of Full Time Equivalent (FTE) budgetary expenses, operational expense, and capital budgets. Analyzes available financial data, investigates budget variances and initiates corrective action or justifies non-adherence. Identifies data and trends to be used for future budget planning. Prepares valid rationale and justification for budget request. Applies current cost containment concepts.
Prepares feasibility studies, cost benefit analyses, and other reports relating to existing and proposed system initiatives.
Participates in establishing and preparing departmental plans, three-year roadmaps, goals, standards, procedures, and instructions, which contribute to the effectiveness of the department in accordance with organizational goals.
Bachelor’s Degree in Heathcare Administration or Business required
Master’s in Healthcare Administration or related field preferred
Strongly desire one of the following certifications/license:
NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM)
Certified Provider Credentials Specialist (CPCS)
or Actively pursuing certification
7-10 years direct experience in developing strategies and business operations for a Centralized Verification Organization and Physician Hospital Organization provider network in a healthcare organization or setting.
5+ years of direct people leadership, preferably leading leaders of people and teams
Strong leadership skills including the ability to communicate vision, negotiate, and lead change to various audiences
Ability to make administrative/procedural decisions and judgments
Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
Knowledge of related accreditation and certification requirements.
Knowledge of medical credentialing and privileging procedures and standards.
Knowledge of medical staff policies, regulations, and bylaws and the legal environment within which they operate.
Knowledge of budget preparation
Ability to understand and apply guidelines, policies and procedures.
Demonstrate ability to analyze, manipulate and understand large amounts of data. Present data and information in a manner that can be understood by all audiences.
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