Under the direction of the Director of the Central Verification Office, provides supervision and evaluation of assigned CVO staff for the enrollment of all University of Toledo Physicians, LLC providers for the UTP, LLC delegated carriers and other plans applicable. Assures credentialing services meet all NCQA, State, and Federal requirements for timeliness and quality. lnterprets and ensures compliance with CVO policies and procedures and all credentialing-related duties for the University of Toledo Medical Center, the UTP, LLC providers, and UTP, LLC delegated carriers.
Coordination and supervision of CVO managed care credentialing process and staff:
· Provides supervision and evaluation of assigned Provider Enrollment credentialing staff, assigns credentialing files and projects, and ensures timely file processing and credentialing submissions to health plans and payors.
· Oversees daily operations of provider enrollment.
· Provides mentoring, training, and education to staff. Acts as an educational resource and is available for consultation to departmental staff. Provides backup resources for staff.
· Responsible for accurate and complete data entry of credentialing/enrollment information into credentialing database.
· Works with database support staff to ensure updates are implemented.
· Summarizes provider information and completes the UTP Credentials reporting grid for Credentials Committee.
· Assures compliance with NCQA Standards, State and Federal requirements, health plan delegation agreements, and department policies.
· Maintains knowledge of NCQA, CAQH, and CMS standards.
· Maintains and tracks a list of new providers in credentialing process via spreadsheet distributed to UT Faculty.
· Completes audit of signed enrollment applications and required documentation for completeness and accuracy.
· Coordinates and facilitates troubleshooting with Revenue Cycle team to resolve any issues related to credentialing and associated billing and collections of revenue.
· Oversees staff responsible for notification process for UTP Department Billing Coordinators and appropriate staff to initiate charge entry and release of charges.
· Review and update UTP policies and procedure as needed in accordance with NCQA standards. Evaluate, implement and maintain process, policies and procedures.
· Responsible for the oversight of submission or comprehensive rosters and reports to delegated plans according to the requirements of the delegation agreement.
· Oversight and monitoring of CAQH online credentialing database.
Delegated Plan Audit Process:
· Oversee and support Health Plan desktop audit process for the UTP delegated plans.
· Oversee and support biennial NCQA accreditation survey process.
· Provide support and guidance for providers being submitted to UTP Credentials Committee to ensure files are complete accurate and submitted timely in accordance with NCQA standards.
· Prepare for onsite audits by the Delegated Plans when applicable.
· Oversee all job functions that support maintenance of NCQA or other certifications.
· Oversees maintenance of accurate information of provider office information for provider directories.
· Perform special projects as assigned.
· Perform other duties as assigned.
Qualifications/Knowledge, Skills & Abilities
Bachelor's degree or equivalent training in Business Administration or Management required.
Three years of direct credentialing and primary source verification experience.
Five years of provider enrollment or enrollment management experience.
Knowledge of Microsoft Access, Word, and Excel necessary.
Extensive working knowledge of NCQA standards. Participation in past NCQA accreditation surveys preferred.
Knowledge of primary source verification, State and Federal credentialing standards and requirements including ongoing monitoring and reporting responsibilities.
NAMSS certification preferred (CPMSM/CPCS). If not currently certified, the successful candidate must be eligible to obtain NAMSS certification within two years of being hired.
Experience and working knowledge of CAQH online database.
Experience with PECOS and other government payor online enrollment systems preferred.
Additional Salary Information: Great benefits: Vacation time, ten (10) paid holidays, sick days; tuition waiver for spouse and dependent children. (Some limitations apply with tuition waiver)
Internal Number: H94139
About University of Toledo Medical Center
University of Toledo Medical Center, Toledo, Ohio
Medical Staff Credentialing Specialist:
Under the direction of the Director of Medical Staff Services, coordinates and performs all credentialing and privileging-related duties for the University of Toledo Medical Center Medical Staff, the University of Toledo Medical Center Allied Health Professional Staff, the University of Toledo Physicians, LLC providers, and UTP, LLC delegated carriers. Provides support to the medical staff, serves as liaison between the medical staff and UTMC administration and ensures medical staff is compliant with applicable hospital and The Joint Commission standards. Assists in: Developing, planning, and management of medical/dental and allied health professionals. Credentialing, Privilege delineation/ reappointment programs that ensure the program’s integrity. Providing general administrative support to the organized medical staff regarding these responsibilities.
The University of Toledo is an equal opportunity, affirmative action employer. The University of Toledo does not discriminate in empl...oyment, educational programs, or activities on the basis of race, color, religion, sex, age, ancestry, national origin, sexual orientation, gender identity and expression, military or veteran status, disability, familial status, or political affiliation.
Great benefits: Vacation time, ten (10) paid holidays, sick days; education waiver at University of Toledo for employee, spouse, and dependent children