Network Health's success is rooted in its mission to create healthy and strong Wisconsin communities. It drives the decisions we make, including the people we choose to join our growing team. Network Health is seeking a Manager of Credentialing/Provider Informatics. This individual is responsible for oversight of the management of the medical and behavioral health credentialing/delegation functions for Network Health Plan in accordance with the NCQA and CMS standards. Responsible for interpretation, explanation and adherence of all regulatory guidelines, bylaws, rules and regulations in the processes required for Practitioner Credentialing. Oversees daily operations of the credentialing/delegation team and manages department activities, assuring time requirements are met and inquiries are answered appropriately. Establishes, implements, and monitors individual and department Key Performance Indicators. Role requires adherence to all applicable departmental regulatory requirements.

This role also provides oversight of daily operations of the Provider Informatics team and manages department activities, assuring time requirements are met and inquiries are answered appropriately. Establishes, implements, and monitors individual and department Key Performance Indicators. Role requires adherence to all applicable departmental regulatory requirements.

Job Responsibilities:

• Recommends and meets annual department goals, initiatives and objectives. Anticipates change and makes adjustments based upon organization strategic plans. Ensures department activities are efficient and effective.
• Manages day to day operations of credentialing department and associates, assigns workloads and manages responsibilities such as hiring, training, staffing coverage, performance evaluation and management, and recognizing accomplishments. Consults with Human Resources leader, as needed.
• Reviews, standardizes, revises and implements existing and new policies and procedures.
• Identifies and evaluates opportunities to enhance internal efficiencies and implements improvement and changes as needed
• Organizes and conducts department meetings informing associates of policy updates, and changes to existing policy and procedures.
• Oversees key performance indicators and measures performance.
• Accountable for integrity of credentialing databases
• Prepares for and responsible for meeting requirements for all internal/external audits and department reporting requirement and requests.
• Accountable for ensuring that all Credentials committee materials and documentation is available as needed before, during and after committee meetings.
• Accountable for all Credentialing Delegated Agreement negotiations with provider entities including all site visits, processes and corrective action plans compliance. Initiates contact and interaction with health plan legal counsel as needed for success.
• Maintains up to date industry knowledge and best practices in daily work
• Maintains ongoing communication with other NHP departments to assess and monitor effectiveness of functions throughout the organization.
• Oversees day to day activities in the PI department and leaders including human resource responsibilities of hiring, training, performance evaluation and management, and recognition. When necessary, consults with Human Resources and leader for guidance.
• Collaborates with leader to communicate department priorities and maintains day to day oversight to ensure department objective and timelines are met.
• Coordinates staffing schedules to ensure optimum staffing levels at all times
• In cooperation with leader, reviews, standardizes and implements existing policies and procedures.
• Identifies and evaluates opportunities to enhance internal efficiencies along with senior staff.
• Informs leader of staff, department, and organization issues and recommends improvements as needed.
• Accountable for integrity of the provider informatics databases
• May participate on workgroups, committees as appropriate
• Organizes, conducts and documents regular 1:1 meeting with direct reports
• Resolves issues/concerns that are not resolvable by direct reports.
• Other duties as assigned

Job Requirements:

• Associate degree or 4 years related experience required
• Bachelor's degree preferred
• 2 years management/leadership experience
• 2 years experience in health insurance environment specific to credentialing and delegation or related area.

Network Health is an Equal Opportunity Employer. We encourage applications from all backgrounds, communities and industries, and are committed to having a team that is made up of diverse skills, experiences and abilities. We are committed to equality and diversity within Network Health.

*WARNING: Please beware of phishing scams that promote work-at-home opportunities and which may also pose as legitimate companies. Please be advised that Network Health recruiter will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for a role with our company. All of our positions require that you first complete an online application.