Job Code/Title: B7043/ Director, Managed Care Contracts and Credentialing
FLSA : Exempt
OPEN UNTIL FILLED
UNM Medical Group, Inc. (UNMMG) is the practice plan organization for physicians and other medical providers associated with the UNM Health Sciences Center. UNM Medical Group, Inc. is a New Mexico non-profit corporation and is an equal opportunity employer. UNMMG offers a competitive salary and an attractive benefit package which includes medical, dental, vision, and life insurance as well as tuition assistance, paid leave and 403b retirement for benefits eligible employees.
The following statements are intended to describe, in broad terms, the general functions and responsibility levels characteristic of positions assigned to this classification. They should not be viewed as an exhaustive list of the specific duties and prerequisites applicable to individual positions that have been so classified.
Under limited supervision, oversees the management and negotiations of a wide range of agreements with Managed Care Organizations to include Commercial, Medicare and Medicaid products. Develops and implements managed care contracting and reimbursement policies for the organization. Ensures compliance with the appropriate accrediting and regulatory agencies as applicable. Supervises staff in the day-to-day management of the contract implementation and credentialing and privileging process and database management.
Duties and Responsibilities
- Initiates and leads joint operation committees with designated major contractors to facilitate contract implementation and compliance.
- Identifies, analyzes, and evaluates contractual compliance issues as they arise; resolves or facilitates resolution of compliance-related problems among constituencies as appropriate.
- Responds to, initiates, and evaluates requests for managed care contracts for multiple product lines and venues; makes recommendations to leadership on appropriate course of action.
- Reviews, negotiates, writes, and processes facility, professional, ancillary and dental contracts for a wide variety of managed care organizations.
- Serves as an expert resource to internal and external constituents with regards to managed care contract planning, reimbursement, interpretation, implementation, and maintenance.
- Directs the development of a managed care utilization, reimbursement and contract database, producing and evaluating contract performance reports, modeling facility and professional (medical and dental) reimbursement rates, evaluating financial contract modifications, and compiling and monitoring key managed care statistics.
- Directs all UNMHSC provider database functions and the Medicare/Medicaid provider enrollment process.
- Manages receipt of credentialing applications, performs review, analysis and prepares files for review with recommendation to the medical staff.
- Manage the privileging process to include initial, re-privilege and expansion requests, ensuring update and maintenance of privileging database.
- Manage the coordination and maintenance of the Ongoing Professional Practice Evaluation (OPPE) and Focused Professional Practice Evaluation (FPPE), re-appointment peer review process.
- Assists in clinical privilege development, maintenance, and periodic reviewed specialty specific clinical privilege criteria and documents.
- Facilitate the Credentialing Workgroup process with oversight of agenda and meeting packet preparation including supporting documentation, minute taking, and credentials summary preparation, information and follow-up on items for POC and Board of Directors.
- Ensure continued compliance with regulatory and accreditation agencies; AAAHC, CMS, NCQA, DOH, Federal and State laws and standards as they relate to Credentialing and Privileging.
- Performs miscellaneous job duties as assigned.
Minimum Job Requirements
Bachelor's degree in related field with at least 7 years of experience directly related to the duties and responsibilities specified. A completed degree from an accredited institution above the minimum qualifications may be substituted on a year for year basis. Verification of education and licensure will be required if selected for hire.
Knowledge, Skills and Abilities Required
Knowledge of computerized information systems used in financial and/or accounting applications.
Organization skills, interpersonal skills, and the ability to manage multiple projects simultaneously.
Ability to work effectively in a team environment.
Analytical and problem solving skills.
Ability to develop strategic and tactical plans, and prioritize and organize projects to meet deadlines.
Ability to bring closure to contracts on time and within designated parameters of profitability.
Advanced fluency in Microsoft Excel and PowerPoint; and database tools such as Microsoft Access.
- Ability to build and maintain strong business relationships with internal and external clients.
Conditions of Employment
NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or obtain certification within twelve months of hire.
Must be employment eligible as verified by the U.S. Dept. of Health and Human Services Office of Inspector General (OIG) and the Government Services Administration (GSA).
Must pass a pre-employment criminal background check.
Fingerprinting, and subsequent clearance, is required.
Must provide proof of varicella & MMR immunity or obtain vaccinations within 90 days of employment.
Must obtain annual influenza vaccination.
If this position is assigned to a clinical area, successful candidate will be required to complete a pre-placement medical evaluation/health screen. Required N-95 mask fitting, testing, vaccinations to include annual TST, Tdap, and Hepatitis B will be determined based on location and nature of position.
Working Conditions and Physical Effort
Work is normally performed in a typical interior/office work environment.
No or very limited exposure to physical risk.
No or very limited physical effort required.