Upper Peninsula Health Plan

This position oversees the development, management, and monitoring of all credentialing and re-credentialing processes, ensuring efficiency and accuracy. The Credentialing Manager contributes and supports Credentialing Verification Organization (CVO) strategic planning, helps prepare the credentialing budget, and ensures compliance with appropriate accrediting and regulatory agencies. This position trains and supervises credentialing staff, supports the Credentialing Committee, and completes credentialing audits as required.  

1. Follows established Upper Peninsula Health Plan (UPHP) policies and procedures, objectives, safety standards, and sensitivity to confidential information.

 

2. Performs all supervisory functions of assigned staff to include scheduling of time off, 90-day and annual performance appraisals, and other appropriate evaluations in compliance with UPHP employee policies; responsible for delegating work among the team, problem solving, and motivating and supporting the credentialing team so they may achieve peak productivity and performance.  

 

3. Obtains and maintains National Committee for Quality Assurance (NCQA) certification for the CVO and health plan accreditation as applicable.  

 

4. Develops, implements, and markets CVO services to hospitals and identifies other CVO growth opportunities.

 

5. Develops, implements, revises, and adheres to established policies, procedures, and objectives to ensure credentialing is in compliance with all licensing standards and accrediting organizations including NCQA, The Joint Commission (JC), Michigan Department of Health and Human Services (MDHHS), Department of Insurance and Financial Services (DIFS), and Centers for Medicare and Medicaid Services (CMS).

 

6. Monitors reports, files, and other output to ensure the team meets key performance indicators with a continued focus on delivering high quality services with efficiency.

 

7. Ensures applications for provider membership and reappointment are processed in accordance with UPHP Policy.

 

8. Maintains accurate and up to date information in the credentialing database and supervises an annual audit of the database, as well as audits by NCQA, MDHHS, CMS, CVO clients, and commercial payer networks. 

 

9. Compiles credentialing reports as necessary for the Credentialing Committee, Management Committee, CEO, COO, medical director, claims, and clinical services.

 

10. Works collaboratively with other internal departments including, but not limited to, provider relations and government programs to ensure effective integration and communication of credentialing requirements and other matters as appropriate. 

 

11. Responsible for maintaining all applicable lists/logs of licenses, insurance, board certification of UPHP providers, and ensures that all providers are screened as required, including but not limited to, review of sanctioned providers from the Medical Services Administration (MSA), Office of Inspector General (OIG), and the Department of Licensing and Regulatory Affairs (LARA).

 

12. Undertakes special projects and assignments and attends meetings as necessary; chairs or participates on committees as requested. 

 

13. Maintains confidentiality of client data.

 

14. Performs other related duties as assigned or requested.

Associate degree in business, health information processing, health information systems, or 

related field

Bachelor’s degree in office or business administration or health care-related area; 

NAMSS Certification as a Certified Provider Credentialing Specialist (CPCS)  

 

Three (3) to four (4) years of progressive office experience

 

Three (3) to four (4) years of credentialing and/or management experience; previous supervisory experience

 

Working knowledge of MS Office (Word, Excel, and PowerPoint)

Keyboarding proficiency

Excellent human relation and oral/written communication

Excellent organizational skills with attention to detail

Ability to work independently and to prioritize tasks

 

 

[This job requires the ability to perform the essential functions contained in the description.  These include, but are not limited to, the following requirements.  Reasonable accommodations may be made for otherwise qualified applicants unable to fulfill one or more of these requirements]:

 

Ability to access departmental files

Ability to enter and access information from a computer

Ability to access all areas of the UPHP offices

Moderate physical effort (lift/carry up to 25 pounds)

Occasionally lifts supplies/equipment

Occasional reaching, stooping, bending, kneeling, crouching

Prolonged periods of sitting

Occasional prolonged standing

Manual dexterity and mobility

 

Works in office conditions, but occasional travel may be required

Subject to many interruptions

Occasionally subjected to irregular hours and evening meetings