Strategic Director: Credentialing & Payor Enrollment

Hudson Regional Health; Hoboken (NJ); On-site; USD 90,000 - 140,000; Full time

Benefits offered by this job

Health insurance

Dental insurance

Vision insurance

401K

Paid time off

Tuition reimbursement

Professional growth

Wellness programs

Job summary

Hudson Regional Health is seeking a Credentialing Manager to oversee the verification process for medical staff and administer credentialing audits across the Managed Care Department. The role requires leading policy development, ensuring regulatory compliance, and coordinating with Health System Entity Medical Staff Committees.

The position demands strong experience in managed care contracting and provider credentialing, with knowledge of CMS, NCQA, URAC, and state regulations.

Qualifications

• Bachelor’s Degree or equivalent professional experience in Healthcare is required.
• CPMSM and/or CPCS Certification is preferred.
• Five or more years in healthcare managed care contracting experience.
• Working knowledge of both Managed Care and Provider Insurance Credentialing is required.
• Working knowledge of government and non-government insurance, payer requirements, and healthcare operations is required.
• Excellent knowledge of healthcare revenue cycle, CMS and state regulations and healthcare compliance requirements/activities is required.

Responsibilities

• Responsible for all aspects of the verification process for medical staff.
• Develops and implements policies and protocols related to physician, nurse and other employee verifications.
• Ensures that the organization and staff are in accordance with all standards.
• Resolving escalated issues within the department.
• Prepares credentials file for completion and presentation to Health System Entity Medical Staff Committees, ensuring file completion with time periods specified.
• Leads, coordinates and monitors the review and analysis of practitioner applications and accompanying documents ensuring applicant eligibility.
• Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures resolution.
• Administer credentialing audits and conducts internal file audits.
• Monitors the initial, reappointment and expirable process for all medical staff, Allied Health Professional staff, other health professional staff and delegated providers.
• Ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, Federal and State) as well as medical staff Bylaws, Rules and Regulations.
• Develop and trains staff on regulations, policies and procedures.
• Responsible for the regular review of internal processes in order to evaluate quality and efficiency within the Managed Care Department; recommend, administer and implement multiple activities in support of the Managed Care Department initiatives.
• Work with Managed Care Leadership to find efficiencies that will improve processes and communication.
• As a working supervisor, research and respond to routine, non-routine, complex and escalated inquiries in a timely and professional manner.
• Work with various departments to prevent issues as well as resolve elevated billing, reimbursement, health plan participation and credentialing issues.
• Maintain awareness of Payor Managed Care activities for changes in policies, authorization requirements and other processes that impact the Practice.
• Maintain the Payor matrix, including limited network participation, to ensure information is accurate and up to date.
• Maintain standard operating processes and procedures for contract monitoring and renewals.
• Gather current data and monitors changes on plan membership, patient volume, plan/benefit structure, reimbursement and other information needed to complete the contract profile.
• Review fee schedules for accuracy and identifies significant changes in reimbursement.
• Oversee activities responsible for ensuring that all Providers are credentialed with Payors and Hospitals in a timely and accurate fashion.
• Promptly communicate credentialing status to applicable parties.
• Monitor Payor directories to ensure all providers are listed accurately by plan
• Monitor trends to avoid minor issues from having a major impact on reimbursement and collections.
• Other duties as assigned.

Education

Bachelor’s Degree or equivalent professional experience in Healthcare

CPMSM and/or CPCS Certification

Job description

Hudson Regional Health is seeking a Credentialing Manager to oversee the verification process for medical staff and administer credentialing audits across the Managed Care Department. The role requires leading policy development, ensuring regulatory compliance, and coordinating with Health System Entity Medical Staff Committees.

The position demands strong experience in managed care contracting and provider credentialing, with knowledge of CMS, NCQA, URAC, and state regulations.