Director of Credentialing and Payer Enrollment (4087)

**PRIMARY DUTIES** **Manage internal credentialing and privileging (C&P) process, including:** - Ensure that all clinical staff are fully credentialed and privileged upon hire and that credentials and privileges are reviewed and renewed at least every 2 years - Ensure that clinical staff maintain valid, active licenses and registrations - Ensure C&P policy and procedures fulfill all HRSA and other applicable requirements - Ensure C&P process is streamlined and as efficient as possible for clinical staff and C&P committee - Supervise C&P staff and ensure that C&P committee operates effectively - Ensure optimal use of available technology (VerityStream) to support streamlined C&P process - Ensure that all required C&P documents are properly collected, reviewed and archived - Prepare for and participate in C&P audits and other reviews (e.g., HRSA OSV and FTCA site visits) **Manage payer enrollment process, including:** - Establish and renegotiate payer contracts, including ensuring optimal payment rates - Clinic site enrollment and revalidation with CMS, Medicaid and commercial insurance - Clinician enrollment and revalidation with CMS, Medicaid and commercial insurance - Management of clinician CAQH profiles and other administrative requirements of payer enrollment - Creation and management of clinician and clinical site NPI numbers - Ongoing follow-up on payer enrollment delays and errors (e.g., inappropriate disenrollment) - Navigate CMS, TMHP and insurance company bureaucracies to effectively address payer enrollment issues and reduce lost revenue due to enrollment errors and delays - Create and implement payer enrollment procedures to ensure that all aspects of payer enrollment are performed promptly and accurately and that overall enrollment timeline is minimized - Supervise payer enrollment staff - Initially collaborate with third-party payer enrollment service while developing plan to promptly insource all payer enrollment activities - Collaborate with Director of Billing Operations to track and resolve denials related to payer enrollment - Provide payer enrollment status information to relevant stakeholders (practice managers, schedulers, etc.) to ensure patients are scheduled with in-network clinicians - Demonstrate a commitment to the mission, core values, and goals of Waco Family Medicine and its healthcare delivery, including the ability to deliver exceptional patient focus with quality, compassion, and respect - Other duties as assigned by supervisor **Director of Credentialing and Payer Enrollment** **REPORTS TO**: Chief Operating Officer **JOB SUMMARY:** Director of Credentialing and Payer Enrollment **EDUCATION AND EXPERIENCE:** Associate or bachelor’s degree; advanced degree (e.g., MBA, MHA) preferred. Minimum of 2 years of experience in a related role; management experience strongly preferred. **SKILLS:** Strong understanding of healthcare requirements related to credentialing and privileging of clinical staff as well as ability to navigate complex administrative requirements for enrolling clinical sites and staff with Medicare, Medicaid, and commercial insurance plans. Strong ability to manage multiple tasks, prioritize work efficiently and proactively follow up on unresolved issues. Excellent verbal and written communication skills to interact effectively with staff and payers. Attention to detail and strong analytical skills, including ability to navigate complex bureaucratic systems. Familiarity with or ability to quickly master credentialing software (VerityStream), electronic health record systems (Epic), and Microsoft Office suite. Commitment to providing excellent service to both internal and external stakeholders. Ability to analyze data, trends, and patterns. Skill in exercising initiative, judgment, discretion, and decision-making to achieve organizational objectives. Ability to understand and adhere to complex compliance requirements. **PHYSICAL AND MENTAL REQUIREMENTS:** - Visual and auditory accu…