Credentialing Manager
Credentialing Manager
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1 Vacancy
Job Description
Use Your Strengths at Wellmark as a Credentialing Manager!
In this critical role you will oversee and enhance provider application processes ensure adherence to network participation standards and drive digital enrollment advancements. Joining our team means taking ownership of high-impact projects collaborating with stakeholders and shaping compliance frameworks that uphold state and federal guidelines. Your expertise will help streamline credentialing operations empowering us to deliver exceptional service in a dynamic healthcare environment.
The ideal candidate applies an inquisitive and analytical mindset in their work is proactive in identifying opportunities for improvement and excels in problem-solving and detail-oriented decision-making. With a solid foundation in provider credentialing risk management and industry regulations you will bring exceptional communication and facilitation skills to the forefront. Your ability to prioritize and manage complex projects will enable you to optimize enrollment processes address compliance challenges and immediately contribute to Wellmarks operational excellence and efficiency.
Qualifications :
Preferred:
- Established relationships within the local provider network.
Required:
- Bachelors degree in science business accounting or related field or equivalent experience.
- 4 years of related work experience including the understanding of provider application and network participation process with the ability to speak to requirement changes.
- 1 year of experience with risk management (i.e. compliance with guidelines policy procedure applicable state/federal law).
- Ability to lead projects and enhancements specific to electronic enrollment.
- Excellent analytical diagnostic problem-solving skills. Strong attention to detail and the ability to identify research and analyze issues organize information and make appropriate decisions.
- Exceptional written and verbal communication skills with the ability to clearly and concisely communicate and/or present complex information to internal/external stakeholders; strong presentation and facilitation skills.
- Proactive self-starter with effective time management skills and the ability to organize and prioritize projects or tasks with little supervision. Ability to adjust to changing priorities and business needs.
- Ability to operate independently yet cooperatively on teams to appropriately manage priorities while maintaining positive relations.
- Demonstrated ability to interpret and apply technical knowledge to policies and procedures.
- Demonstrated experience in process improvement.
- Up to 5% travel required.
Additional Information :
a. Serve as lead resource for all Delegated Credentialing Entities for provider credentialing re-credentialing and change requests on behalf of Wellmark Inc. preparing and communicating regularly on policy updates revisions and general program and import file requirements. Provide education to others on electronic transfer processes.
b. Manage contracts and amendments for delegate activity including facilitation between the delegate authorized signer and Wellmark Legal. Includes activity for any new delegate as well as regulatory or other updates.
c. Coordinate external provider credentialing and support the peer review process including preparation facilitation of meetings with providers and follow-up on committee decisions with correspondence to providers and coordination of next steps.
d. Communicate in a timely manner with Delegated Credentialing Entities and Network Administration leadership about electronic loading error results and recommend file and/or system changes to reduce errors. Provide updates and communication with any Delegated Credentialing Entities and Network Administration leadership regarding errors changes etc.
e. Influence providers to act in a delegated capacity through education partnership and relationship building.
f. Lead the in-depth implementation audit of any new delegated entities and the periodic audit of existing delegated entities.
g. Lead initiatives for people process or system changes between Wellmark and delegated entities including changing requirements to import files change in systems and new regulatory requirements.
h. Partner with the Network Administration leadership and Technology teams to execute and maintain the provider data loading process electronically and monitor the delegates related to current Wellmark policies file formats and procedures and NCQA requirements.
i. Perform risk management and ongoing monitoring and take appropriate action as needed. Support the member complaint process against providers including assisting in the determination of whether complaints are service or quality of care issues. Assist with the request and preparation of materials for review by the director or legal. Process denials and termination as needed and according to established procedures and applicable state and federal laws (i.e. National Practitioner Data Bank/NPDB).
j. Support audits of Wellmarks credentialing process by coordinating questions and documentation from delegated entities completing interviews with auditors in a SME function and in general assisting the Provider Compliance & Policy Manager as needed.
k. Collaborate within and outside of Operations to coordinate and drive Administration Program Increment (PI) planning deliverables.
l. Identify continuous improvement opportunities across Network Administration and drive department level continuous improvement initiatives. Coordinate provider appeal processes recruit hearing panel members and complete follow-up steps to panel decisions (i.e. reporting information to licensing boards and NPDB).Track/document outcomes in database and for reporting as appropriate.
m. Participate in meetings and/or project requirements regarding changes to provider credentialing. Represent department on various projects/initiatives and serve as resource and trainer for Credentialing team.
n. Provide support and coaching as needed to Associate Credentialing Manager and other Network Administration team members executing deliverables for delegated entities.
o. Maintain credentialing policies and procedures and manuals regarding network risk management. Maintain revise and regularly update Network Administrations Risk Management Playbook work process flow diagrams and supporting work instructions. Ensure adherence and compliance with any contractual regulatory obligations and other applicable accreditation requirements.
p. Other duties as assigned.
An Equal Opportunity Employer
The policy of Wellmark Blue Cross Blue Shield is to recruit hire train and promote individuals in all job classifications without regard to race color religion sex national origin age veteran status disability sexual orientation gender identity or any other characteristic protected by law.
Applicants requiring a reasonable accommodation due to a disability at any stage of the employment application process should contact us at
Please inform us if you meet the definition of a Covered DoD official.
Remote Work :
No
Employment Type :
Full-time
Employment Type
Full-time
