POSITION SUMMARY:

Accountable for delegated credentialing for all markets and products. Ensures delegated credentialing is compliant with the standards established by the National Committee for Quality Assurance (NCQA), WV Bureau of Medical Services, WV Office of Insurance Commissioner, Ohio Department of Insurance, the Centers for Medicare and Medicaid Services, and other regulatory agencies, as needed. Oversee delegated credentialing process, from pre-delegation assessment to monthly file receipt and processing to annual audits. Prepare for and attend WV Medicaid, NCQA and other regulatory audits, as required.

REQUIRED:

1. College degree and/or four years related healthcare experience.
2. Previous credentialing and auditing experience.
3. Strong organizational, interpersonal, and critical thinking skills.
4. Excellent communication skills, both written and verbal.
5. Ability to multi-task, prioritize workload to meet deadlines, and attention to detail.
6. Experience with Microsoft Office programs (Outlook, Excel, Word, etc.), and Adobe Acrobat.

DESIRED:

1. Bachelor’s Degree.
2. CPCS Certification.
3. Previous supervisory experience.
4. Knowledge of national accreditation standards, state, and federal regulations.

RESPONSIBILITIES:

• Oversees all delegated provider credentialing functions to ensure compliance.
• Performs pre-delegated audits and annual assessment audits to ensure delegated entities are compliant with THP policies and procedures as well as all accreditation, regulatory, and governing entities.
• Prepares pre-delegated annual assessment audits including scheduling audits and sending pre and post audit letters and communications.
• Oversee the delegated staff including compliance with performance standards, allocation of work, training, development, PTO requests, and annual performance standards.
• Recommend and implement change in policies and procedures.
• Create and review internal and external reporting of participating providers.
• Reports all audit outcomes to management and uploads results into THP’s online monitoring tool (OMT).
• Supervises delegated credentialing team to ensure timely maintenance of delegated provider data.
• Responsible for compliance with NCQA delegated credentialing compliance.
• Assists with national, state, and internal audits.
• Oversees delegated credentialing agreement compliance.
• Works collaboratively with the Provider Delivery Services team as well as all internal departments.