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The Manager of Credentialing is a critical position within our System of Care Credentialing Department that is a required position within our contract budget. The position is critical to maintaining the System of Care Credentialing activities we will manage on behalf of the County. This position is responsible for processing the system of care provider applications & primary source verification for completing the provider credentialing and re-credentialing processes. This position will work with leadership to create processes and management of credentialing activities into database tracking ensuring high quality standards are maintained. This position will be responsible for conducting audits, provide feedback to reduce errors and improve processed and performance. Responsible for the development of system of care credentialing policies and procedures.
As part of this position, you will be required to be granted and maintain access to the County of San Diego’s electronic health record, Cerner Community Behavioral Health (CCBH). In addition, please note that if you are currently employed by the County of San Diego, further review of your application will need to occur to ensure that there is not a conflict of interest.
- Review application materials to determine if system of care providers meet qualifying criteria for credentialing
- Provide oversight and compare application information to credentialing sources to ensure accuracy and completeness of provider application information
- Educate internal and/or external stakeholders regarding credentialing application processes (e.g., DEA guidelines; CDS guidelines)
- Ensure verifications are completed within state, federal, and/or internally mandated timeframes (e.g., NCQA; CMS)
- Contact primary sources, credentialing agencies, and/or reference on-line information sources in order to verify system of care provider credential information (e.g., licenses; education; Board certification; DEA and/or CDS)
- Identify potential process improvement needs to system of care provider analysis and verification procedures
- Sets team direction, resolved problems and provides guidance around credentialing operations
- Manages the internal and external audit requests for provider files and processes to respond to these
- Provides oversight for credentialing process and documentation to providers and contracted agencies that credentialing and re-credentialing processes are completed
- Runs reports from provider databases to track credentialing and re-credentialing activities for the variety of provider types
- Facilitates the tracking of providers’ malpractice insurance, DEA, and licensure renewals to ensures they are current/active
- Facilitates the resolution of credentialing issues and coordinates and completes external and internal notification requirements
- Reviews state and federal bulletins for provider sanctions; review provider disbarment reports and notifies concerns to leadership
- Attend and participate in meetings to achieve departmental and interdepartmental goals and objectives
- Triages provider related issues and escalates complex problems when necessary to leadership
- Builds and maintains productive relationships with system of care network providers and their administrative organizations
- Assists with system of care network credentialing activities development and handle follow-up activities
- Oversee delegated relationships with external partner to ensure credentialing practices are performed in accordance to contractual agreements
- Manages the processes of entry and maintenance of system of care providers’ data into multiple databases resulting in accurate provider directories
- Documents communication with system of care providers and/or administrative organization in the designated databases; assists in managing the integrity of databases by using contacts with providers to verify and update provider files
- Provide input into policy changes or updates and/or respond to corrective action requests regarding analysis and verification processes and related documents
- Assume additional responsibilities as assigned
- High School Diploma / GED (or higher)
- 2+ years experience in managed care credentialing
- Proficient with Microsoft Excel (general spreadsheet navigation, data entry and data sorting), Microsoft Word (creating and editing documents) Outlook (email and calendar)
- 2+ years experience working in an environment that requires coordination of benefits and utilization of multiple groups and resources
- Demonstrate knowledge of industry terminology (e.g., medical and behavioral health)
- Demonstrate knowledge of applicable state and federal laws, policies, and regulations (e.g., state-specific license requirements; Controlled Dangerous Substances license requirements; DEA)
- Demonstrate knowledge of credentialing procedures, policies, and terminology (e.g., NCQA; URAC)
- Knowledge of provider information storage and retrieval systems (ie: CAQH, National Practitioner Data Bank (NPDB) or similar)
- Knowledge using data analytics of key operating indicators (e.g., quality percentages; turnaround time) or performance standards experience
- Requires up to 25% local San Diego travel to provider sites
- Associate’s Degree (or higher)
- Microsoft Excel (pivot tables and vlook ups)
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Keywords: Credentialing, Manager, Credentialing Manger, Controlled Dangerous Substances, credentialing procedures, NCQA, URAC, CAQH, NPDA, National Practitioner Data Bank, San Diego, CA, Optum