Job description

POSITION DESCRIPTION
Job Title: Credentialing and Enrollment Manager II February 2023
Department: Central Billing Office Exempt
Job Code: 170469

PRIMARY PURPOSE:
The Credentialing and Enrollment Manager is primarily responsible for the day-to-day operations regarding provider credentialing and enrollment. The Credentialing and Enrollment Manager utilizes policies and procedures to ensure that SEP is adhering to all federal, state and local regulatory requirements to ensure compliance with NCQA standards and delegated contractual requirements. The Credentialing and Enrollment Manager is a highly visible position that is always responsible for creating a positive impression with associates, providers, leadership and other visitors he/she encounters, both in person and on the phone. The Credentialing and Enrollment Manager may, at any time, perform duties for any area within the Credentialing and Enrollment department.

DUTIES AND RESPONSIBILITIES:
POSITION DUTIES - ESSENTIAL FUNCTIONS
ACCOUNTABILITY TOOLS
FREQUENCY
1. Understands and upholds SEP’s Mission, Vision, and Values.

• Service Standards Agreement
• 360 Degree evaluations

Ongoing
2. Complies with all applicable laws and regulations.

• REACH training

Ongoing
3. Oversees accurate and timely completion of all new provider credentialing and enrollment applications and ongoing maintenance.

• Complete and accurate applications

As Needed
4. Maintains, evaluates, and prepares payroll.

• Accuracy of employee payroll

Approve
bi-weekly
5. Participates in the interviewing, hiring, and disciplinary actions related to associates.
As Needed
6. Monitors employees with regards to attendance, job performance, and audits their daily work within the department.
Daily
7. Coordinates employee schedules and maintains appropriate staffing levels.

• Full Employees Daily

Daily
8. Coordinates, assesses and performs training to employees and all other stake holders.
As Needed
9. Maintains leadership role and assists in promoting growth and development of employees.
Daily
10. Responsible for initiating and auditing changes related to NCQA accreditation, delegated contracts as well as other insurance companies.
Daily
11. Delegates job responsibilities accordingly to employees.
Daily
12. Handles complaints and upset patients in a professional manner.
As Needed
13. Oversees the provider & group data into the system and ensures that electronic files are complete, current and accurate.

• Current and accurate spreadsheets, files, etc.

Daily
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14. Manages the maintenance of provider and group files to ensure they are complete, current, and accurate.

• Complete provider & group files

As Needed
15. Ensures that accurate and timely information is provided to all applicable contacts.
As Needed
16. Maintains network and billing systems files for groups and providers ensuring they are current and accurate.

• Current and accurate spreadsheets, applications, processes, etc

Daily
17. Effective and timely communication with site and CBO for addressing credentialing and enrollment issues.

• Employees feedback

Daily
18. Manages the appropriate EPIC WQ’s to ensure accuracy.
Daily
19. Attends and participates in insurance provider rep meetings and any additional meetings that may require input from the Credentialing and Enrollment departments.
As Needed
20. Reviews and makes updates to departmental workflows.
As Needed
21. Supports the Administrator of Credentialing and Enrollment as requested.
Ongoing
22. Other duties as assigned.
As Assigned

ORGANIZATIONAL RELATIONSHIPS:
The title of this position’s immediate supervisor: Administrator of Credentialing and Enrollment
Job titles of persons reporting to this position, if any: Credentialing Specialist
Number of associates supervised: 6-10

FINANCIAL IMPACT AND RESPONSIBILITIES:
The Credentialing and Enrollment Manager is accountable for activities that support meeting St. Elizabeth Physicians’ Central Billing Office goals and objectives. The Credentialing and Enrollment Manager is responsible to support all members of the administrative and management teams.

EDUCATION:
Position
Minimum Education
(position-specific)
Work Experience
(position-specific)
Leadership Experience Required
(position-specific)
Time Allotted to Gain Required Education Minimum
Role Expansion due to growth of department
Internal/External Applicant (Internal applicant elects to apply for an open position)
Credentialing & Enrollment Manager II
High School diploma/GED
2 years experience in the medical industry
1 year of leadership/coaching**
N/A
Minimum education required at time of application
Page 3 of 4

YEARS OF EXPERIENCE:
3+ years in an administrative medical environment
1 - 2 years Management experience desired

REQUIRED SKILLS AND KNOWLEDGE:
Ability to manage and prioritize multiple tasks, knowledge of Excel, Word, Outlook and PowerPoint and the ability to learn other computer skills. Must have good organizational skills and work professionally with doctors, hospital administration and management, SEP associates and the public.

OTHER REQUIRED SKILLS AND KNOWLEDGE:
1. Understanding and knowledge of various computer application processes.
2. Credentialing database management and report writing.
3. Knowledge of NCQA and delegated contracting.
4. Knowledge of credentialing and primary source verification.
5. Knowledge of medical insurance and managed care plans.
6. Skills in establishing and maintaining effective working relationships.
7. Effective communication with providers, insurance company representatives, co-workers, and leadership.
8. Ability to work independently and perform job duties with minimal direction
9. Demonstrated ability to work successfully in a team-based decision-making culture.
10. Demonstrated ability to work independently resulting in effective outcomes and on-time performance.
11. Experience in planning and coordinating multi-disciplinary communications strategies, strategic initiatives, and events.
12. Must respond and follow through to requests from customers promptly.
13. Must work carefully and precisely with attention to detail.
14. Must utilize resources wisely.
15. Performs duties willingly and with initiative. Shares necessary information so co-workers can do the same.
16. Cooperates with other departments and work groups.

LICENSES AND CERTIFICATIONS:
CPB or CPC desired for other billing departments
PHYSICAL DEMANDS BY POSITION
(4 = Very Frequent)
ACTIVITY
1
2
3
4
ACTIVITY
1
2
3
4
ACTIVITY
1
2
3
4
Walking
X
Reaching
X
Hearing
X
Sitting
X
Manual Dexterity
X
Normal
Conversation
X
Pushing
X
Use of Hands
X
Other
Sounds
X
Pulling
X
Talking
X
Vision
X
Climbing
X
Lifting
X
Acuity, Near
X
Stooping
X
Over 50 lbs.
X
Acuity, Far
X
Kneeling
X
Under 50 lbs.
X
Color Vision
X
Standing
X
Other*

• Please specify:

MENTAL REQUIREMENT:
Page 4 of 4
Demonstrates both problem solving and problem prevention skills. Displays sensitivity to the need of patients, families, visitors, physicians, coworkers and other external customers. Demonstrates excellent communication skills and empathy. Treats others with consideration, courtesy and respect. Remains composed and takes actions to restore calm in stressful situations. Demonstrates judgment and tact when dealing with others.

WORKING CONDITIONS:
Responsible; works independently in a safe and appropriate manner. Timely; recognizes time as a customer’s most valuable resource and responds promptly. Accurate; works carefully and precisely with attention to detail. Coordinated; organizes and delivers service in the proper order; utilizes resources wisely.
Performs duties willingly and with initiative; shares necessary information so co-workers can do the same. Cooperates with other hospital departments and work groups.
This position functions in a normal office environment (little exposure to excessive noise, dust, and temperature). Local travel required between work locations.
The routine duties of this position involve the low potential for exposure to blood borne pathogens and other potentially infectious materials and has a low risk for exposure to Tuberculosis.

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