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Job Description Summary:

The Credentialing Program Manager reports to the Medical Affairs Manager and/or Director. The primary purpose of the position is to direct, monitor and provide quality credentialing/privileging and re-credentialing/privileging processes to ensure that physicians and allied health practitioners meet applicable accrediting, legal, and regulatory standards. This Credentialing Program Manager identifies and assesses areas of compliance according to TJC, ODH, CMS and other accreditation agencies. The Credentialing Program Manager serves as the content expert as it pertains to the credentialing process and responds to any inquiries regarding the credentialing/re-credentialing process from providers, hospitals, outside agencies/institutions, and other entities. In addition to medical providers, this individual interacts with medical staff office(s), quality management, compliance, medical staff and hospital leadership, and other professionals as necessary to ensure the integrity of the credentialing process. The Credentialing Program Manager is responsible for a systematic, disciplined approach to ensure provider data accuracy and integrity, and independently investigates and validates information to report trends. Leads process improvement activities to ensure operating efficiencies of the credentialing process. This Credentialing Program Manager works directly with medical staff leadership regarding discrepancies identified in provider applications and may act as a liaison to state medical licensure boards. The Credentialing Program Manager works independently under general supervision with considerable latitude for initiative and independent judgement.

Responsibilities And Duties:

70% Credentialing - Core Functions of the Credentialing Program Manager:

Conduct, participates in, and maintains credentialing and privileging.

Completes evaluation of a credentialing application to determine applicant’s initial eligibility for privileges. Analyzes application and supporting documents for completeness.

Verifies and documents expirable using acceptable verification sources to ensure compliance with accreditation and regulatory standards.

Performs detailed and thorough review of applications, primary source verifications, and sources provided.

Independently investigates and validates the information and escalates findings as needed.

Recognizes potential discrepancies and adverse information, and independently investigates and validates information in applications, primary source verifications, or other sources.

Determines the applicant’s initial eligibility for privileges based on approved criteria.

Compiles, evaluates and presents the practitioner-specific data collected for review by one or more decision-making bodies.

Serves as the main point of contact for the practitioner during the application process, providing timely updates and additional information as requested.

Manages the credentialing, recredentialing and privileging process.

Uniformly applies clearly defined credentialing/privileging processes to all practitioners.

Evaluates credentialing/privileging requests and evidence of education, training, and experience to determine eligibility for requested privileges.

Complies with internal and external requirements related to verifying the status of all practitioner expirables (e.g. licenses, certifications) by querying approved sources and recommending actions to ensure compliance.

Completes quality review of all completed appointment/reappointment files which includes, file audit check list completion, all supporting documentation, all query requirements, and file organization.

Facilitates the review of Physician and Allied Health Practitioner credentialing files. Is an active participant on Physician Credentials Committee and/or Allied Health Practitioner Committee by compiling and presenting related materials for committee action and prepares report for the Medical Executive Committee and Board of Trustees for final approval.

Serves as liaison with clinical departments for the purpose of medical staff credentialing and privileging and collaborates with managers and directors of other hospital departments to ensure that Physicians and Allied Health Practitioners are only performing procedures for which they are privileged.

Conducts, participates in, and maintains current clinical competency evaluations [FPPE/OPPE, proctoring].

Analyzes and prepares presentations and reports regarding practitioner performance improvement and ensures quality/competence data is clear, concise and structured.

Recognizes, investigates, and validates discrepancies and adverse information obtained.

Coordinates an appropriate evaluation of data gathered by physician leaders.

Communicates findings and/or resulting actions to supervisor and department leadership.

Manages the proctoring and training pathway process for physicians and Allied Health Practitioners.

The Credentialing Program Manager conducts research regarding credentialing criteria for the development of new procedures and collaborates with leadership in the development of new clinical programs. Develop pathways and processes for education and training for new technology.

Helps identify and implement process improvement initiatives and always looking for ways to streamline processes to increase efficiency.

Comply with accreditation and regulatory standards [TJC, ODH, CMS].

Leads the credentialing file review session during all regulatory and CMS directed surveys.

Is a content expert regarding credentialing and requires in depth knowledge regarding TJC, ODH, and CMS credentialing requirements, as well as the specific medical staff privileging information for the hospitals they support.

Obtains and evaluates practitioner sanctions, complaints and adverse data to ensure compliance.

Participates in an ongoing assessment of governing documents (bylaws/rules and regulations/policies and procedures) to ensure continuous compliance.

Participates in surveys and audits of regulatory and accreditation agencies or organizations.

Demonstrates an understanding of state and regulatory standards.

20% Organized Medical Staff:

Collaborates with Physician and Allied Health Practitioner leadership to develop and maintain delineation of privileges (DOPs), complex departmental and section rules and regulations.

Leads the on-boarding process for all Physicians and Allied Health Practitioners new to an OhioHealth hospital. This includes orientation to the hospital, introduction to medical information systems, overview of clinical offerings and resources at the hospital, computer access, etc. Coordinates activities to introduce new providers to the Medical Staff, Hospital leadership, and hospital associates.

Plans and facilitates events for the Medical Staff and Allied Health Practitioners. This includes coordinating activities with various vendors, marketing/communications, hospital executives, and the Medical Staff leadership.

May be involved with managing medical students at the campus level with regards to clinical rotations.

Manages the billing and collection of medical staff dues.

Creates and manages both open and one-time purchase orders.

Manages Medical Staff meetings as directed which require agenda planning, coordination with the meeting chair, tracking of follow-up items from previous meetings, coordination of guest speakers, and compiling of meeting minutes that may be reviewed by the Governing Body, and external regulatory agencies that are reviewed by the board and frequently reviewed during accreditation surveys.

10% Data Management:

Maintains the credentialing database continuously and consistently to ensure that accurate and current information is available to all stakeholders.

Manages the on-call directory to ensure that call schedules are maintained and accurate.

Collaborates with providers to ensure their contact preferences are accurate so they can be contacted accurately and efficiently to prevent delays in care for patients.

Maintains confidentiality regarding provider information. This individual has access to confidential provider information so a high degree of discretion and sensitivity in communications is required. Absolute confidentiality must be maintained.

Audits, assesses, and effectively utilizes and maintains practitioner credentialing processes and information systems (e.g. files, reports, minutes, databases) as outlined by the department.

Identifies associations between seemingly independent problems or events to recognize trends, problems, and possible cause-effect relationships.

Securely manages information as the single source of truth by effectively navigating database software and maintaining data integrity.

Manages or participates in special projects as needed.

The major duties, responsibilities and essential functions listed above are not intended to be all-inclusive of the duties and responsibilities to be performed by associates in this job.

Minimum Qualifications:

Bachelor's Degree (Required)

Additional Job Description:

degree and two years’ experience in the healthcare, managed care, credentialing or medical staff services field or equivalent combination of education and 7+ years’ experience in healthcare, managed care, credentialing or medical staff services field

SPECIALIZED KNOWLEDGE

Knowledge of physician and allied practitioner credentialing processes. Detailed understanding of TJC, ODH, and CMS credentialing requirements. Strong communication skills, both written and oral; strong organizational skills and attention to detail; credentialing database management (Cactus or similar credentialing database); team/associate accountability and conflict resolution. Excellent interpersonal and customer services skills. Critical thinking and problem solving skills are essential.

DESIRED ATTRIBUTES

Certification as a Provider Credentialing Specialist (CPCS) or Medical Staff Coordinator (CMSC) preferred.

Work Shift:

Day

Scheduled Weekly Hours :

40

Department

Medical Affairs

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Equal Employment Opportunity

OhioHealth is an equal opportunity employer and fully supports and maintains compliance with all state, federal, and local regulations. OhioHealth does not discriminate against associates or applicants because of race, color, genetic information, religion, sex, sexual orientation, gender identity or expression, age, ancestry, national origin, veteran status, military status, pregnancy, disability, marital status, familial status, or other characteristics protected by law. Equal employment is extended to all person in all aspects of the associate-employer relationship including recruitment, hiring, training, promotion, transfer, compensation, discipline, reduction in staff, termination, assignment of benefits, and any other term or condition of employment