Manager, Provider Certification & Credentialing (Finance)

We offer remote work opportunities (AK, AR, AZ, CO, FL, HI, IA, ID, IL, KS, LA, MD, MN, MO, MT, NE, NV, NM, NC, ND, OK, OR, SC, SD, TN, TX, UT, VA/DC, WA, WI & WY only).

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Veterans, Reservists, Guardsmen and military family members are encouraged to apply!

Job Summary

Manages provider certification, credentialing, and data operations to ensure that the department meets regulatory requirements, accreditation standards, established goals, and performance metrics. Administers accreditation the processing of provider certifications, initial credentialing, re-credentialing, delegated credentialing, and provider demographic for direct and corporate contracted providers. Coordinates routine provider data reviews to ensure TriWest databases/systems have current and accurate provider information. Ensures timely research and resolution of provider certification, credentialing, and data inquiries/requests. Leads communication with internal and external stakeholders to resolve provider certification, credentialing, and/or data issues. Monitors and reports team's performance against established goals and metrics on a regular basis. Oversees the certification and credentialing activities and programs of the network subcontractors and external CVOs. Maintains compliance with all regulatory requirements and accreditation standards related to provider certification, credentialing, and data. Ensures processes and documentation, including policies and procedures, adhere to applicable federal guidelines as well as accreditation standards.

Education & Experience

Required:

• Bachelor's degree in healthcare administration, business administration, or related field; or equivalent experience
• 3+ years of credentialing experience in a leadership role
• 3+ years of provider data management system experience
• U.S. Citizen
• Must be able to receive a favorable Interim and adjudicated final Department of Defense (DoD) background investigation
• Thorough knowledge of provider credentialing processes (initial, re-credentialing, delegated), provider certification processes, provider data management processes, accreditation standards for URAC and/or NCQA, and regulatory requirements for VA CCN and/or TRICARE
• Experience with credentialing applications/provider data management systems

Preferred:

• Strong analytical and process improvement skills
• Excellent written and verbal communication skills
• Ability to review and interpret regulatory requirements

Key Responsibilities

• Manages the daily operations for and staff performing initial credentialing, re-credentialing, and delegated credentialing.
• Oversees the daily operations for and staff performing provider certifications.
• Coordinates the loading and maintenance of provider data (including adds, changes, and terms) for direct and corporate contracted providers. Ensures provider data is entered into the credentialing database according to established guidelines and procedures.
• Assists with the annual review and maintenance of certification and credentialing policies and procedures to ensure compliance with applicable federal requirements and accreditation standards.
• Manages the preparation and responses for all credentialing-related audits, including but not limited to, internal, monthly and annual regulatory, as well as accreditation audits.
• Serves as the point of contact for certification and/or credentialing-related questions from network subcontractors and representatives from federal agencies.
• Develops and administers the annual audit plan for all delegated entities, including network subcontractors, direct contracted providers, and corporate contracted providers. • Routinely reviews department procedures and processes to identify opportunities for improvement, incorporating existing or new technologies, tools, and resources.
• Assists with reviewing and ensuring provider-facing documents/materials includes current and accurate certification and/or credentialing information.
• Manages the team's workload to ensure established performance goals and production metrics are met on a daily/weekly/monthly basis. Ensures staff performance issues are addressed timely and performance improvement plans implemented as needed.
• Conducts annual performance reviews according to TriWest guidelines.
• Oversees staff training and development. Communicates new and/or changes to existing processes, regulations, and standards to staff in a timely manner.
• Ensures staff is fully informed through regular team meetings and individual staff concerns/issues are addressed through regular 1:1 meetings.
• Assists with identifying and justifying additional resource needs for the team to ensure performance goals are met as well as compliance with regulatory requirements and accreditation standards.
• Attends meetings outside of normal business hours as required.
• Regular and reliable attendance at work.
• Performs other duties as assigned.

Competencies

Coaching / Training / Mentoring: Actively foster actions required for desired business outcomes through ongoing constructive feedback. Develop and deliver effective team training for processes, regulatory requirements, accreditation standards, and applications/systems. Guide staff in the creation of professional development plans.

Communication / People Skills: Ability to influence or persuade others to meet organizational goals and department objectives; adapt to different work styles and team members from different backgrounds. Effective written and verbal communication; active and critical listening; cross-functional collaboration with internal and external stakeholders.

Computer Literacy: Ability to function effectively in a multi-system environment using Microsoft applications, department-specific tools and applications, as well as organization-wide systems.

Coping / Flexibility: Resiliency in adapting to a variety of situations and stakeholders while maintaining a sense of purpose and professional approach to problem solving.

Empathy / Customer Service: Customer-centric focused; helpful mindset; ability to have patience, respect, and empathy for others.

Information Management: Ability to manage effectively analyze a large amount of data/information, draw sound conclusions, and concisely communicate findings to various stakeholders.

Leadership: Successfully manage different styles of employees from different backgrounds. Provide clear direction and effective coaching.

Multi-Tasking / Time Management: Prioritize and manage tasks to meet changing deadlines and requirements within a high volume, high stress environment.

Organizational Skills: Ability to organize people and tasks, adjust to changing priorities, as well as learn and apply new requirements and guidelines, within time constraints and with available resources; detail-oriented.

Team-Building / Team Player: Influence the actions and perception of others in a positive and constructive manner. Build team commitment and consensus.

Technical Skills: Working knowledge of URAC standards, VA CCN and TRICARE regulations and requirements, as well as medical terminology. Current and thorough knowledge of primary source verifications for initial credentialing and re-credentialing. Current and thorough knowledge of delegated credentialing processes. Working knowledge of credentialing applications and provider data management systems. Proficient with Microsoft applications (Outlook, Teams, Word, Excel, PowerPoint, and SharePoint) and other tools.

Working Conditions

Working Conditions:

• Availability to cover any work shift as needed
• Travel may be required
• May work within a standard office environment
• Extensive time utilizing a computer with prolonged sitting
• Must be able to obtain appropriate security clearance

Company Overview

Taking Care of Our Nation's Heroes.

It's Who We Are. It's What We Do.

Do you have a passion for serving those who served?

Join the TriWest Healthcare Alliance Team! We're On a Mission to Serve®!

Our job is to make sure that America's heroes get connected to health care in the community.

At TriWest Healthcare Alliance, we've proudly been on that important mission since 1996.

DoD Statement

Our Department of Defense contract requires US citizenship and a favorably adjudicated DOD background investigation for this position.

Benefits

We're more than just a health care company. We're passionate about serving others! We believe in rewarding loyal, hard-working people who are willing to learn as they grow. TriWest Healthcare Alliance values teamwork. Join our team, fulfill your responsibilities, and you may also be considered for frequent pay raises, overtime opportunities to earn even more, recognition and reward programs, and much more. Of course, we also offer a comprehensive and progressive compensation and benefits package that includes:

• Medical, Dental and Vision Coverage
• Paid time off
• 401(k) Retirement Savings Plan (with matching)
• Short-term and long-term disability, basic life, and accidental death and dismemberment insurance
• Tuition reimbursement
• Paid volunteer time

TriWest job postings typically include a salary range, which can vary based on the specific role and location, but generally this position ranges from around $99,000 to $104,000 per year.

Equal Employment Opportunity

TriWest Healthcare Alliance is an equal employment opportunity employer. We are proud to have an inclusive work environment and know that a diverse team is a strength that will drive our success. To that end, TriWest strives to create an inclusive environment that supports diversity at every organizational level, and we highly encourage candidates from all backgrounds to apply. Applicants are considered for positions based on merit and without discrimination on the basis of race, color, religion, sex, sexual orientation, gender identity, national origin, age, disability or any other consideration made unlawful by applicable federal, state, or local laws.