Credentialing Specialist/SME

Summary

Join our growing healthcare team in Chicago as the Manager of Credentialing and Credential Verification (CVO)! This role offers significant growth opportunities, involving consultative credentialing services with global talent. You will lead a team overseeing licensing, credentialing, and privileging processes, ensuring compliance. Responsibilities include physician accreditation, insurance enrollment, provider data management, and market analysis. You will also verify credentials, maintain databases, generate reports, and handle provider inquiries. Strong leadership, payer relationship management, and process optimization skills are essential. This position requires a Bachelor's degree (Master's preferred) and 6-10 years of experience in credentialing leadership.

Requirements

• Bachelor's degree in healthcare administration, Business, or a related field; master's degree preferred
• 6 to 10 years of experience in credentialing, with substantial experience in a leadership role
• In-depth knowledge of credentialing processes, privileging, and regulatory requirements
• Strong organizational and project management skills
• Excellent communication skills
• Skilled in preparing and delivering presentations to C Suite stakeholders

Responsibilities

• Lead and oversee a team that oversees the end to end Licensing/ CVO, Credentialing and Privilege processes to ensure compliance with industry standards and regulations
• Process physician accreditation, managed care, governmental and commercial insurance enrollment and re-credentialing
• Daily provider data management and review of credentialing files for accuracy and completeness, utilizing internal and external sources
• Analyze local payor IPA markets for partnerships or payer contracting opportunities
• Perform primary source verification via various state and national sources
• Oversees, updates and maintains provider credential database including CAQH, PECOS, NPPES Registry, Sharepoint any other applicable regulatory agencies
• Develops and prepares analytical reports monthly/quarterly of the summary of credentialing activity
• Responds timely to provider inquiries by letter, phone or internal communication
• Work closely and maintain relationships with provider relations at each payer, and communicates any challenges and/or concerns with manager timely
• Mentor and coach the team to provide highest levels of service and efficiency
• Maintain relationships with key Payers to facilitate negotiation of contracts
• Collaborate with internal departments to streamline and optimize credentialing operations
• Manage client relationships and provide high customer satisfaction
• Develop and implement policies and procedures to maintain the highest standards of credentialing excellence in the internal teams
• Stay informed about changes in accreditation and certification requirements and update processes accordingly
• Provide thought leadership via adoption of best practices based on industry changes and technology adoption

Preferred Qualifications

Established relationship with key payers will be a plus

Benefits

• Health insurance
• Hybrid/Remote