Manager, Credentialing (32575)

POSITION PURPOSE

The Manager, Credentialing and Payer Operations oversees the credentialing and recredentialing application process for health care providers across all health plans. This position ensures compliance with credentialing guidelines and maintains a thorough understanding of the credentialing requirements of each health plan with which GI Alliance is contracted. The Manager stays current on insurance regulations, managed care contracts, payer policies, and fee schedules.

KEY RESPONSIBILITIES

Payer Credentialing Strategy

• Partner with market leaders to understand the payer landscape. Define payer credentialing efforts accordingly, including review of pre-onboard data to confirm that payers align with agreements and volume remains intact after onboarding.
• Direct and prioritize team efforts so that providers can bill and collect by their defined start dates, and ensure credentialing is completed before the effective date with each health plan.
• Work closely with the M&A team to manage credentialing and payer operations challenges on each project.
• Resolve patient access issues pending payer corrections, loading, or credentialing so that patients are not affected.

Managed Care Liaison

• Build and maintain payer relationships outside of managed care to resolve escalated payer issues, across all payers.
• Collaborate with internal teams to resolve loading issues and claims not paid per contract.
• Drive process improvement.
• Serve as a resource for contract language and RCM support with claim adjudication interpretation.
• Assist the Director of Payer Relations as needed with escalated credentialing issues and contractual variance escalations within the assigned region.

Revenue Cycle - Credentialing

• Resolve claims issues that flow to the payer team worklist within the billing platform in assigned markets.
• Identify and resolve root causes of internal issues that lead to credentialing- or payer-related denials.

Data Management

• Maintain the internal credentialing database and Excel spreadsheets on a routine basis.
• Support fee schedules and vendor data requests within assigned regions as requested by leadership.

KNOWLEDGE, SKILLS, AND ABILITIES

• Ability to work independently and collaborate as part of a team
• Ability to lead projects and workstreams
• Ability to manage and prioritize multiple tasks in a fast-paced, dynamic environment and to meet deadlines
• Excellent written and verbal communication skills
• Strong interpersonal skills and professional demeanor, with the ability to build and sustain professional relationships
• Meticulous attention to detail and quality of work product
• Excellent time management and organizational skills
• Working knowledge of Microsoft Word and Excel
• Understanding of HIPAA, Joint Commission, NCQA, and CMS standards and patient confidentiality regulations payer
• Knowledge of contracting methodologies, claim adjudication process, and contract language.

Education: Bachelor's degree, or equivalent work experience (10 years).

Experience:

• Minimum of 10 years of work history in Managed Care Operations
• Ability to work in a team-oriented environment