Senior Registered Nurse (RN) - PCU - Progressive Care Unit
Children's Medical Center Dallas
Dallas, TX

Job Title & Specialty Area: Sr Credentialing Specialist

Department: Managed Care

Location: Dallas, TX

Shift: Monday - Friday

Job Type: Remote in Texas

Why Children’s Health?
At Children's Health, our mission is to Make Life Better for Children, and we recognize that their health plays a crucial role in achieving this goal.

Through our cutting-edge treatments and affiliation with UT Southwestern, we strive to deliver an extraordinary patient and family experience, ensuring that every moment, big or small, contributes to their overall well-being.

Our dedication to promoting children's health extends beyond our organization and encompasses the broader community. Together, we can make a significant difference in the lives of children and contribute to a brighter and healthier future for all.

Summary:
The Sr. Managed Care Credentialing Specialist is responsible for performing credentials verification for Children's Health employed and contracted practitioners and those who join 162.001(b) provider groups to ensure compliance with standards set forth by National Committee Quality Assurance (NCQA), Center for Medicare and Medicaid Services (CMS), Texas Medicaid & Healthcare Partnership(TMHP) and contracted payers. Directly responsible for credentialing and enrollment for organizational providers, CHST hospital facilities and ancillary services. This position is responsible for submitting accurate and complete provider and organizational, and facility providers enrollment applications, following up with payer credentialing departments and provider enrollment representatives to ensure providers are fully credentialed and loaded as participating with all applicable contracted health plans. Managed Care Credentialing Specialists are accountable for maintaining and disseminating accurate plan participation status reports and billing information to all applicable Children's Health internal departments to maximize collections in the revenue cycle management process. Function as subject matter expert and serves as a liaison in resolution of payer related issues and optimizing revenue cycle management.

Responsibilities:

• Directly responsible for credentialing of organizational providers, CHST facilities and ancillary services. Oversight of credentialing and payer enrollment of complex hospital groups. Facilities initial enrollment and revalidation with the Centers for Medicare and Medicaid Services (CMS), State Medicaid programs, and key contracted Managed Care Organizations. Prepare credentialing files for individual and organizational providers per NCQA, CMS, and contracted payer standards. Perform primary source verification (such as, licensure, education, board certifications, malpractice claims etc.) using pre-approved sources, documenting verification efforts consistent with Children’s Health Provider Credentialing policies.
• Obtain, verify, and maintain complete and accurate demographic information and required licensure/ certification documentation for supported individual practitioners and organizational providers. Collaborate with multiple departments to obtain and retain current copies of certificates, etc. Maintain the accuracy of the credentialing database. Maintain the accuracy of provider CAQH profiles and re-attest every 120 days. Responds to inquires from other healthcare organizations, interface with department key stake holders, providers, and delegates for requests related to credentialing information.
• Responsible for administrative oversight of the Credentialing Committee meetings. Present files to Committee Chair and Credentialing Manager for review and auditing prior to committee meetings, highlighting red flags for peer review and discussion. Assist with facilitating meetings, prepare quarterly reports, dashboards and meeting minutes. Ensure the functions or activities of the committee meetings are in accordance with the NCQA requirements.
• Manage the enrollment process for CMS & TMHP enrollment and commercial plans for supported individual and organizational providers. Coordinate the gathering and verification of necessary data, working directly with practitioners or appropriate representatives. Complete applications accurately and thoroughly, meeting standards set forth by CMS, HHSC, and commercial payers. Obtain application signatures from the authorized signatory and provide all required supporting documentation. Submit applications and follow up diligently to ensure timely processing. Respond to deficiency notifications in a timely manner. Follow up diligently on provider addition requests and communicate provider changes, corrections, and terminations. Continuously monitor enrollment process for improvements. Collaborate with Legal and Accreditation to ensure regulatory and compliance requirements are met.
• Responsible for creating, maintaining and disseminate plan participation status and billing information to all applicable Children’s Health internal departments and third-party billing agencies (as applicable) to maximize collections in the revenue cycle management process.
• Responsible for delegated credentialing policy interpretation and compliance. Responsible for annual payor credentialing file audits. Oversees delegated credentialing roster submission and tracking. Work with delegated payer contacts to address concerns within the delegation process while cultivating relationship with delegated payers.
• Works collaboratively with Credentialing Manager and Coordinator to promote data integrity and to optimize effectiveness of the Credentialing database, ensuring consistency in data entry rules. Supports the implementation of new database modules applicable to Managed Care. Implementation includes data migration and validation, as well as data mapping to demographic reports, participation reports, and training.
• Complete a quarterly roster reconciliation process for all supported practitioners with applicable health plans. Verify accuracy and communicate additions, changes, and corrections in a timely manner, along with necessary supporting documentation.
• Serves as a liaison in resolution of payer issues and optimizing revenue cycle management. Support Patient Financial Services and other Children’s Health billing departments by working collaboratively with payers. Participate in special claim projects, coordinating with Provider Relations/Network Management as needed. In collaboration with the Credentialing Manager and Sr. Director, will develop strategic departmental goals to continuously promote efficiency in network participation, reducing denials and increasing net revenue.
• Functions as the subject matter expert for the credentialing department. Provides training related to credentialing and payer enrollment that enhances knowledge, develop skills and enrich the team.
• Oversee special projects including, but not limited to, providing project plans, foreseeing possible concerns, and responsible for regular project updates with leadership.
• Responsible for delegated credentialing policy interpretation and compliance. Responsible for annual payor credentialing file audits. Oversees delegated credentialing roster submission and tracking. Work with delegated payer contacts to address concerns within the delegation process while cultivating relationship with delegated payers.
• Excellent interpersonal skills and ability to work efficiently with internal and external customers. Maintain positive working relationships with payer representatives, providers, and all Children’s Health internal departments.
• Perform other duties and special projects as assigned.

 How You’ll Be Successful:

Other information:
WORK EXPERIENCE
At least 4 years in Payor Relations or Credentialing with an insurance company, hospital, or other large group of providers. Required

EDUCATION

• Two-year associate's degree or equivalent experience Required
• Four-year bachelor's degree or equivalent experience Preferred

A Place Where You Belong

We put our people first. We welcome, value, and respect the beliefs, identities and experiences of our patients and colleagues. We are committed to delivering culturally effective care, creating meaningful partnerships in the communities we serve, and equipping and developing our team members to make Children’s Health a place where everyone can contribute.

 Holistic Benefits – How We’ll Care for You:

· Employee portion of medical plan premiums are covered after 3 years.

· 4%-10% employee savings plan match based on tenure

· Paid Parental Leave (up to 12 weeks)

· Caregiver Leave

· Adoption and surrogacy reimbursement 

As an equal opportunity employer, Children's Health does not discriminate against employees or applicants because of race, color, religion, sex, gender identity and expression, sexual orientation, age, national origin, veteran or military status, disability, or genetic information or any other Federal or State legally-protected status or class. This applies to all aspects of the employer-employee relationship including but not limited to recruitment, hiring, promotion, transfer pay, training, discipline, workforce adjustments, termination, employee benefits, and any other employment-related activity.