TPR Credentialing Director (Hybrid based in Dallas, TX)
Company: Tenet Healthcare
Location: Dallas
Posted on: October 14, 2024
Job Description:
JOB DESCRIPTION:
- Works with market leaders nationally to understand manpower
plan in each market and define payor/credentialing efforts
accordingly. This activity includes reviewing pre-onboard data to
ensure the payors align with the Tenet agreements and 100% of
volume remains intact post-onboard.
- Directs and prioritizes team efforts to ensure providers can
bill and collect by the providers defined start date.
- Works with the onboarding team closely to manage changes with
each project.
- Drive the data to all practices to ensure patient management on
the front-end aligns with our agreements.
- Resolve patient access issues pending payor
corrections/load/credentialing to ensure patients are not impacted
due to administrative challenges.
- Achieve and maintain NCQA Accreditation so delegated strategy
can be rolled out to all payors.
- Build and navigate sensitive payor relationships outside of
managed care to resolve major issues within TPR. This includes all
payors Tenet has agreements with - to include CMS and Medicare MACs
and Medicaid Leadership.
- Communicate super-specialist providers onboarding to ensure the
enhanced rates are tied to this portfolio by health plan.
- Collaborate with managed care to resolve loading issues and
claims not paid per contract.
- Delegated credentialing agreement negotiations.
- Special projects that drive revenue from a contracting/steerage
perspective and prioritize managed care efforts based on TPR market
need.
- Challenge payor agenda to drive process improvement on the
front and back-end - including delegation.
- Contract language interpretation and ensures alignment across
physician practices.
- Manage IPA relationships.
- Resolve claims issues that flow to the credentialing worklist
within the billing platform in all markets that are related to
credentialing disconnects and/or education opportunities.
- Denial management for all payors including CMS
(Medicare/Medicaid).
- Responsible for creating billing scenarios in the billing
platform that mirror the credentialing structure for all
payors.
- Root cause resolution for internal challenges that causes
denials (file maintenance, RCM, Athena partners).
- Make adjustment recommendations on 'dead' A/R.
- Projects either nationally or at the market level - as
assigned:
- Large dollar/out of the box strategies that must be managed to
completion.
- Supervises the initial and re-credentialing process for the TPR
Credentialing Staff assuring credentialing accuracy and timely
follow-up.
- Advises key individuals regarding credentialing issues i.e.
interprets standards and regulations to assure compliance with
State Board of Medical Examiners, NCQA, CMS and other regulatory
agencies, identifies "red flags", recommends solutions and/or
alternatives for unusual situations credentialing applications
received.
- Works with the CMO to manage the credentialing committee for
TPR to make internal credentialing decisions on the entire
portfolio for our delegated partners and ensures there is
consistently a diverse specialty mix membership.
- Ensures Policies and Procedures are maintained with latest
regulatory updates at an NCQA, State Mandate and CMS level at all
times.
- Responsible for communicating with our health plan contacts on
a routine basis to ensure ongoing and accurate participation status
for our employed physicians at all sites in which the physician is
rendering services. This includes initial
credentialing/re-credentialing and requests for additional
sites.
- Maintains an accurate and up-to-date credentialing
database.
- Overseeing the overall operations and supervision of the
Credentialing Department, including routine credentialing activity
and management of department staff.
- Includes employee selection, counseling, evaluations,
disciplinary action, and terminations; development/revision of
credentialing policies and procedures, credentialing job
descriptions, required in-service education, etc.
- Ensures staff meet productivity standards set for the
department. REQUIREMENTS:
- High school diploma/GED is required.
- Bachelor's degree in healthcare management, public health,
accounting, finance, business, social or behavioral sciences
preferred or equivalent work experience.
- 7-10 years of previous managed care leadership experience
and/or 5+ years' experience in a credentialing leadership
role.
- Must have the ability to travel up to 25% nationally. Selected
candidate will be required to pass a Motor Vehicle Record
check.
- Knowledge of primary source verification, provider enrollment,
and NCQA credentialing requirements.
- Excellent analytical abilities and communication skills
including the ability to communicate with stakeholders and
decision-makers across the spectrum of the organization, from
senior business leaders to subordinates.
- Experience in progressive health care management with emphasis
in health plan/provider contracting and physician group
management/contracting.
- In depth knowledge of health plan and governmental payer
credentialing, enrollment, and requirements.
- Ability to work within a deadline-intense environment.
- Demonstrated problem-solving and customer service skills.
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Keywords: Tenet Healthcare, DeSoto , TPR Credentialing Director (Hybrid based in Dallas, TX), Executive , Dallas, Texas
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