WACO FAMILY MEDICINE

Discussion

Director of Credentialing and Payer Enrollment (4087)

Open 19d

Summary

Manages clinical staff credentialing and privileging processes plus payer enrollment operations for a healthcare organization, ensuring provider licenses are current, overseeing HRSA compliance, negotiating payer contracts, and supervising staff—using VerityStream and CAQH platforms to streamline enrollment timelines and minimize revenue delays.

PRIMARY DUTIES

Manage internal credentialing and privileging (C&P) process, including:

  • Ensure that all clinical staff are fully credentialed and privileged upon hire and that credentials and privileges are reviewed and renewed at least every 2 years
  • Ensure that clinical staff maintain valid, active licenses and registrations
  • Ensure C&P policy and procedures fulfill all HRSA and other applicable requirements
  • Ensure C&P process is streamlined and as efficient as possible for clinical staff and C&P committee
  • Supervise C&P staff and ensure that C&P committee operates effectively
  • Ensure optimal use of available technology (VerityStream) to support streamlined C&P process
  • Ensure that all required C&P documents are properly collected, reviewed and archived
  • Prepare for and participate in C&P audits and other reviews (e.g., HRSA OSV and FTCA site visits)

Manage payer enrollment process, including:

  • Establish and renegotiate payer contracts, including ensuring optimal payment rates
  • Clinic site enrollment and revalidation with CMS, Medicaid and commercial insurance
  • Clinician enrollment and revalidation with CMS, Medicaid and commercial insurance
  • Management of clinician CAQH profiles and other administrative requirements of payer enrollment
  • Creation and management of clinician and clinical site NPI numbers
  • Ongoing follow-up on payer enrollment delays and errors (e.g., inappropriate disenrollment)
  • Navigate CMS, TMHP and insurance company bureaucracies to effectively address payer enrollment issues and reduce lost revenue due to enrollment errors and delays
  • Create and implement payer enrollment procedures to ensure that all aspects of payer enrollment are performed promptly and accurately and that overall enrollment timeline is minimized
  • Supervise payer enrollment staff

  • Initially collaborate with third-party payer enrollment service while developing plan to promptly insource all payer enrollment activities

  • Collaborate with Director of Billing Operations to track and resolve denials related to payer enrollment

  • Provide payer enrollment status information to relevant stakeholders (practice managers, schedulers, etc.) to ensure patients are scheduled with in-network clinicians

  • Demonstrate a commitment to the mission, core values, and goals of Waco Family Medicine and its healthcare delivery, including the ability to deliver exceptional patient focus with quality, compassion, and respect

  • Other duties as assigned by supervisor

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