Manager, Provider Data Management & Credentialing

Location: Chesterfield, MO
Position Purpose: Manage the operations of all credentialing and provider data management functions for multiple business units ensuring compliance with National Committee for Quality Assurance (NCQA), Department of Health and Human Services (DHHS), Center of Medicaid/Medicare Services (CMS) and other regulatory standards.
  • Oversee the credentialing and re-credentialing of all physicians, mid-level practitioners and organizational providers according to the plan specifications for multiple business units
  • Oversee the provider setup processes ensuring accurately and timely setup for claims payment, member assignment and directory display
  • Ensure compliance with NCQA and DHHS credentialing requirements and participate in activities related to plan NCQA accreditation
  • Collaborate with the health plans and various departments on network expansion efforts, large claims and contract amendment projects and various related initiatives
  • Identify process improvement opportunities to decrease cost, improve quality and increase efficiency within the department
  • Review and update departmental policies and procedures to ensure compliance with NCQA, CMS and other regulatory agencies
  • Monitor Medicaid and Medicare sanctioning reports to ensure compliance with Health Care Financing Administration (HCFA) requirements regarding prohibition of excluded provider participation
  • Facilitate Credentialing Committee activities and serve on Quality Improvement Committees, when needed
Education/Experience: Bachelor’s degree in related field or equivalent experience. 5+ years of combined management and provider data management, credentialing or healthcare operations (i.e. claims processing, billing, provider relations or contracting) experience, preferably in a managed care or insurance environment. Previous experience as a lead in a functional area, managing cross functional teams on large scale projects or supervisory experience including hiring, training, assigning work and managing the performance of staff.
April A. Estes
Senior Recruiter
720-439-2609 Direct
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