[Hiring] Provider Credentialing & Enrollment Manager @PM Pediatric Care

Role Description

This is a remote position. The Provider Credentialing and Enrollment Manager will oversee the processing of applications and reapplications for providers. This role ensures compliance with national accreditation standards and state and federal regulatory requirements. The position requires a subject matter expert in all state bylaws of the credentialing process and application management, specifically tailored for urgent care environments.

Responsibilities

• Ensure provider staff is credentialed and enrolled with payers to ensure sufficient clinical coverage and minimal claims reimbursement denials.
• Develop and implement policies and procedures for the credentialing and recredentialing process, ensuring they meet industry standards and organizational needs.
• Manage the primary source verification of education, training, board certification, work history, and licensure of healthcare providers.
• Maintain CMS NPPES reporting.
• Support internal credentialing committee in evaluation of newly hired staff.
• Facilitate the resolution of discrepancies or concerns regarding applicants’ credentials, working closely with medical staff leadership and healthcare providers.
• Maintain accurate and confidential credentialing databases and files, ensuring the security and integrity of sensitive provider information.
• Effectively communicate accurate enrollment and credentialing status throughout the organization to support effective decision making.
• Assist the accounts receivable department with credentialing related payer denials.
• Coordinate with counsel and compliance on malpractice and related insurance coverage.
• Serve as the lead expert on all state-specific bylaws, ensuring that urgent care and health system applications adhere to varying regional legal standards.

Qualifications

• Minimum of five (5) years of progressively responsible operational or consulting experience in provider credentialing and enrollment in an outpatient setting.
• Proven expertise in all state bylaws governing the credentialing process for urgent care or multi-site health systems.
• Knowledge and experience of the healthcare industry or medical financial operations.
• Possess ability to identify patterns and conduct root cause analysis.
• Maintain accurate and up-to-date provider credentialing information in the database.
• Experience with CAQH (Council for Affordable Quality Healthcare) database and application process.
• Strong attention to detail and organizational skills.
• Demonstrated ability to manage multiple, concurrently running projects and adapt to changing deadlines, competing priorities and unexpected assignments.

EEO Statement

PM Pediatric Care is an equal employment opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, gender, sexual orientation, gender identity or expression, national origin, disability status, protected veteran status or any other characteristic protected by law.