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Job Summary and Responsibilities

You have a purpose, unique talents and now is the time to embrace it, live it and put it to work. We value incredible people with incredible skills – but your commitment to a greater cause is something we value even more. This is the heartbeat of our organization and your time will be spent in a supportive, team environment with resources to help you flourish and leaders who care about your success.

This position has dually aligned responsibilities, while striving for excellent quality of patient care; 1). Payer Credentialing initial and re-credentialing files, and 2). Facility Credentialing & Privileging: Coordinates and completes all required medical staff and health professional applications, forms and delineation of privileging information for our medical staff partners. Coordinates a comprehensive specialized credentialing program to assure compliance with the payer credentialing requirements and delegated carrier agreements and NCQA requirements that are built into our policies and procedures. Manages our NCQA certification, and annual delegated commercial payer audits assigned.

+ Serve as the technical resource regarding NCQA accreditation standards, adherence to delegated policies, delegated commercial agreements, and policies and procedures governing the OMA credentialing staff.

+ Manages Malpractice Group coverage, application process, evaluate information reported and submit to applicable carriers for review and certificate of coverage.

+ Manages provider's DEA; link to appropriate clinic location for supply and pharmaceutical savings programs.

+ Responsible for assigned annual delegated payer audits; building relationships, understanding unique requirements of delegated agreements, creating file review rosters, file review audit (electronically), coordinating quality reporting, reviewing findings and responding to findings with OMA leadership support.

+ Understands and engages in National Committee for Quality Assurance (NCQA) requirements, to effectively work with our delegated commercial payers.

+ Become subject matter expert on NCQA, URAC, CMS standards, delegated credentialing policies and procedures, and update in policy software.

+ Must be able to manage a high volume of provider files, while maintaining completion prior to targeted effective dates.

+ Analyze essential data within the applications and all additional relevant documentation/information to ensure compliance with all payer, NCQA, federal and state regulatory requirements, Medical Staff Bylaws and affiliated documents, and TJC standards for initial appointment, reappointment in an independent, efficient, and timely manner.

+ Compile and authenticate Commercial Payer and Government Enrollment, Medical Staff, Allied Health applications and waiver requests in compliance with payer and regulatory requirements and accreditation standards. This includes, but is not limited to, the primary source verification of information, collection and analysis of information received, and pursuit of additional information as necessary.

Job Requirements

In addition to bringing humankindness to the workplace each day, qualified candidates will need the following:

+ Working knowledge of NCQA, URAC, The Joint Commission, CMS, and Department of Health standards.

+ Successful experience with previous delegated commercial payer audits preferred.

+ Proven leadership skills: ability to develop and sustain trusting work relationships, ability to educate and motivate team members, ability to communicate effectively with various levels of professionals, ability to self-regulate and meet deadlines, ability to use critical thinking and strategic approaches in problem

+ Associate degree preferred

+ Bachelor degree preferred

+ Two (2) years of healthcare-related physician/allied health professionals credentialing experience, medical staff related experience, or degree in business administration or medical staff services in management, in lieu of experience.

+ CPMSM or CPCS certification, preferred.

+ High school diploma/G.E.D. Required

Physical Requirements - Sedentary work - prolonged periods of sitting and exert up to 10 lbs. force occasionally

Where You'll Work

We believe in the healing power of humanity and serving the common good through our dedicated work and shared mission to celebrate humankindness.

CommonSpirit Mountain Region’s Corporate Service Center is headquartered in Centennial, CO where our corporate leaders and centralized teams support our hospitals, clinics and people – including marketing, human resources, employee benefits, finance, billing, talent acquisition/development, payor relations, IT, project management, community benefit and more. Many of our centralized teams offer a remote work option which supports a healthy work-life balance while still providing a culture of collaboration and community where incredible people are doing incredible things every day.

Pay Range

$23.33 - $35.53 /hour

We are an equal opportunity employer.