Credentialing Supervisor

To ensure compliance with applicable regulatory laws, rules, regulations, NCQA and Joint Commission accreditation standards and other internal or external customer requirements regarding the CSB aspects of credentialing and privileging.

ACCOUNTABILITIES:

• Knowledgeable of regulatory, accreditation and other external customer requirements regarding credentialing including, but not limited to NCQA, JC, and CMS.

• Responsible to assist the Director and Manager to ensure credentialing processes are in compliance with NCQA, JC, MN Department of Health and CMS.

• Responsible for the supervision, recruitment, orientation, training, development, and day-to-day management of assigned staff.

• Assists the CSB Quality Assurance Coordinators (QAs) in reviewing and auditing of all completed practitioner files ensuring that all necessary elements are present and correct in the file according to corporate, accreditation, regulatory and department standards. Determines if all file and data criteria is met. Records on tracking mechanisms.

• Works collaboratively with QAs to ensure the highest standards of quality and accuracy of the credentialing process.

• Assists the QAs in reviews and audits of data entry of practitioner data in the credentialing database and records results on tracking reports to ensure accuracy, completeness and adherence to established quality standards.

• Reviews records and identifies barriers that encumber desired credentialing results. Develops and implements plans to remove the barriers to achieve highest level of performance.

• Provides mentoring to CSB staff in performing departmental tasks and plans the appropriate course of action for situations not covered by policies and procedures under the direction of the Director. Assists in day-to-day mentoring and coaching.

• Supports the credentialing process which may include tracking, reporting and creating of new procedures and/or policy creation.

• Participates in activities to develop and improve materials, policies, and procedures to support day-to-day operations.

• Participates in activities that support development of database program to assist in the credentialing process.

• Collects and reports data necessary to monitor the CSB credentialing activities.

• Acts as resource for Cactus database issues or questions.

• Works closely with Manager and Director to develop and deliver scheduled in-services and training documentation.

• Conducts audits and works with Credentialing Manager and Director on a variety of credentialing issues to facilitate quality assurance efforts

• Leads improvement processes by identifying trends, recurring issues and communication problems.

• Suggests new processes and/or change to existing process and/or policy and procedure.

• Develops and maintains department training and reference materials.

• Serves as a resource to staff for credentialing related questions.

• Provides day to day operational support, direction and leadership to assigned staff, including problem solving.

• Provides administrative leadership to the CSB staff in the Manager or Director’s absence. This includes providing direction, making appropriate judgment decisions, assuring that there is appropriate staffing in the CSB, coordinating and facilitating staff meetings, etc.

• Remains current with credentialing requirement mandated by external review agencies (e.g., NCQA, JC, and/or state and federal regulations). Works with Manager and Director to modify processes to ensure compliance with such requirements.

• Performs other projects and/or duties as assigned by Manager or Director.

  REQUIRED QUALIFICATIONS:

• Bachelor’s Degree and two years managed care or health care setting credentialing experience, or high school diploma/GED and five years managed care or health care setting credentialing experience.
• Knowledge of and experience dealing with implementing NCQA or JC credentialing standards.
• Minimum of one-year leadership experience.
• Analytical skills required to analyze and interpret data into meaningful reports.
• Ability to work with multiple departments and organizations to deliver results.
• Strong communication skills, verbal and written.

DECISION-MAKING:

• Supervisor is expected to perform independently on a day to day basis within the scope of accountabilities.
• Provide leadership to CSB staff in making appropriate departmental policy decisions and plan the appropriate course of action for situations not covered by policies and procedures, in the absence of the Manager or Director.
• Independently coordinate Medical Director or legal review when appropriate.
• Responsible for the personnel decisions regarding supervisor’s direct reports (Local 12 staff).

We’re a nonprofit, integrated health care organization, providing health insurance in six states and high-quality care at more than 90 locations, including hospitals and clinics in Minnesota and Wisconsin. We bring together research and education through HealthPartners Institute, training medical professionals across the region and conducting innovative research that improve lives around the world.

At HealthPartners, everyone is welcome, included and valued. We’re working together to increase diversity and inclusion in our workplace, advance health equity in care and coverage, and partner with the community as advocates for change.

Benefits Designed to Support Your Total Health
As a HealthPartners colleague, we’re committed to nurturing your diverse talents, valuing your dedication, and supporting your work-life balance. We offer a comprehensive range of benefits to support every aspect of your life, including health, time off, retirement planning, and continuous learning opportunities. Our goal is to help you thrive physically, mentally, emotionally, and financially, so you can continue delivering exceptional care.

Join us in our mission to improve the health and well-being of our patients, members, and communities.

We are an Equal Opportunity Employer and do not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identify, status as a veteran and basis of disability or any other federal, state or local protected class.