Manager, Provider Credentialing - Capital Blue Cross

Position Description

Base pay is influenced by several factors including a candidate’s qualifications, relevant experience, and anticipated contributions to meet the needs of the business, along with internal pay equity and external market driven rates. The salary range displayed has not been adjusted for geographical location. This range has been created in good faith based on information known to Capital Blue Cross at the time of posting and may be modified in the future. Capital Blue Cross offers a comprehensive benefits packaging including Medical, Dental & Vision coverage, a Retirement Plan, generous time off including Paid Time Off, Holidays, and Volunteer time off, an Incentive Plan, Tuition Reimbursement, and more. 

At Capital Blue Cross, we promise to go the extra mile for our team and our community. This promise is at the heart of our culture, and it’s why our employees consistently vote us one of the “Best Places to Work in PA.”

The Manager of Provider Credentialing Services oversees and manages all aspects of the provider credentialing and recredentialing function for Capital Blue Cross. Responsible for: ensuring credentialing/recredentialing is managed and conducted in a timely and accurately manner to meet all business, regulatory, licensure, accreditation, reporting and compliance requirements including NCQA, JCAHO, DOH, CMS and BCBSA; establishing and enforcing credentialing policies and procedures and managing performance within regulatory and accreditation timeframes; setting the direction for the department and achieving departmental and corporate goals related to handling and processing of applications, verification of credentials, data management in the Cactus system, administration of the Credentialing Committee and oversight of all delegated contracts; problem resolution and timely responses to provider inquiries (both participating and non-participating providers); managing the credentials verification process for all Capital Blue Cross medical personnel; training staff within and outside of the department on the use of the CACTUS software; acting as a technical consultant and subject matter expert (SME) on credentialing, recredentialing, delegation, CACTUS and CAQH for internal stakeholders and external entities including health systems, delegated partners, vendors, NCQA, PID, DOH, CMS, and BCBSA; ensuring oversight of delegated entities including contract negotiation and management and processing of electronic files; collaborating with other cross-functional departments

Responsibilities and Qualifications

• Credentialing and Recredentialing: Oversee and manage the credentialing/recredentialing function for all Capital Blue Cross professional providers and facilities (approximately 18K providers). Establish new policies and review/revise existing policies to ensure they meet or exceed NCQA, JCAHO, DOH, CMS, BCBSA and Capital Blue Cross requirements. Enforce compliance with all regulatory and accreditation bodies; oversee and ensure compliance, accreditation, reporting and processing activities are conducted in accordance with standards and within required timelines. Function as the Lead and direct the preparation for regulatory and accreditation reviews/audits from NCQA, PID, DOH, CMS, BCBSA and other entities. Lead and oversee the creation and implementation of process improvement activities to improve efficiencies and administrative costs related to credentialing/recredentialing. Oversee the management and administration of the Capital Blue Cross Credentialing Committees. Work closely with the Credentialing Committee Chair and all members of the Credentialing Committees to ensure timely review and action on all files. Maintain a working knowledge of the required systems/software (CACTUS, CAQH). Engage and collaborate with other Capital Blue Cross departments to maintain and enhance knowledge of regulatory and accreditation requirements, interrelationships, data sharing, projects, etc.
• Delegation: Establish and maintain strong relationships with all delegated entities. Negotiate, manage and ensure compliance with all delegated credentialing agreements. Conduct outreach and cultivate relationships with prospective delegated entities to obtain agreements. Oversee the performance of delegation oversight including audits, pre-contract, and at minimum, on an annual basis, following contract execution. Ensure the quality and timely and accurate processing of delegated electronic DCV files. Research issues, problem solve and ensure timely resolution of delegated matters. Interact with other internal departments to ensure delegated information is flowing as it should be
• Technical/SME Consulting: Act as a technical consultant and SME on all matters relating to credentialing, recredentialing, delegation, CAQH and NCQA, JCAHO, DOH, CMS regulations and standards to providers, vendors, partners, regulatory/accreditation agencies, department staff, Capital Blue Cross IT and other internal departments. Act as a technical consultant and SME on the CACTUS software and CAQH. Identify, research, and resolve technical and operational issues (including outside vendors such as Cactus and CAQH). Ensure all regulatory and accreditation reporting requirements are met. Participate in meetings and discussions to provide information on the CACTUS software, CACTUS capabilities, CAQH, system interrelations, data and report generation. Creatively interpret and address reporting needs and information requests as requested by providers, partners, vendors, NCQA, DOH and all internal departments. Apply knowledge of the system and processes to identify improvement opportunities
• Staff Oversight: Lead and provide overall direction and supervision regarding all credentialing/recredentialing/delegation activities including work assignment, prioritization and performance monitoring. Ensure existing staff are trained on selected systems and regulatory and accreditation requirements, Hire and train new staff, identify development opportunities with respect to operational or technical knowledge, perform all HR duties within stated timelines. Answer questions and resolve problems with judgment and tact using information and knowledge of the subject and the people involved. Conduct performance management activities to ensure a high-performing team

Skills:

• Demonstrated organizational and time management skills. Self-motivated and able to work independently with little supervision. Excellent verbal, written, and presentation skills. Ability to communicate effectively and work with all levels within and outside of Capital Blue Cross. Strong decision making, problem solving and research skills. Ability to analyze complex problems and issues, determine impact, and develop business solutions or recommendations for changes. Ability to convey complex or technical information in a manner that others can understand. Ability to manage workload to meet regulatory and accreditation timeframes.

Knowledge:

• Technical understanding and ability to use systems and software including Cactus, CAQH, Facets, Adobe/Nuance, Microsoft Office. Comprehensive understanding of NCQA, JCAHO, DOH and CMS standards and requirements
• Must be able to lead and motivate individuals within an ever-changing and time-constrained environment to achieve results. Demonstrated character, competence, conviction and courage to influence and garner support of team and others in accomplishing departmental and corporate goals and objectives. Build and maintain valuable business relationships in a fast-paced environment

Experience:

• A minimum of five years’ experience in managing credentialing/recredentialing/ delegated functions

Education and Certifications:

• Bachelor’s degree in a related health care field or a minimum of five years’ management experience in credentialing

Work Environment:

• Sedentary work involving significant periods of sitting, talking, hearing, keying and performing repetitive motions. Work requires visual acuity to perform close inspection of written and computer generated documents as well as a PC monitor. Working environment includes typical office conditions.

Physical Demands:

• While performing the duties of the job, the employee is frequently required to sit, use hands and fingers, talk, hear, and see. The employee must occasionally lift and/or move up to 5 pounds.

Location:

• This position is classified hybrid, which requires onsite work on Tuesdays and Wednesdays.

About Us

We recognize that work is a part of life, not separate from it, and foster a flexible environment where your health and wellbeing are prioritized. At Capital you will work alongside a diverse and caring team of supportive colleagues, and be encouraged to volunteer in your community.  We value your professional and personal growth by investing heavily in training and continuing education, so you have the tools to do your best as you develop your career.      And by doing your best, you’ll help us live our mission of improving the health and well-being of our members and the communities in which they live.