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Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in provider credentialing and claims management, with a strong focus on health plan and governmental payer requirements. Proven ability to lead teams, manage relationships, and drive strategic initiatives in a deadline-driven environment.
Highest-signal resume keywords
Provider Credentialing ManagementClaims Issue ResolutionHealth Plan ContractingCredentialing Systems ProficiencyAnalytical Problem-Solving
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Provider EnrollmentMedical Claims PaymentPrimary Source VerificationNCQA Credentialing RequirementsRoot-Cause AnalysisRevenue Cycle Management (RCM)SOP DevelopmentData AnalysisPerformance Metrics ManagementProject Management
Soft Skills
Communication SkillsCustomer Service SkillsTeam LeadershipTraining and DevelopmentInterpersonal Skills
Tools & Technologies
Echo Credentialing SystemAthenaMicrosoft Office Suite
Industry Keywords
Healthcare ManagementManaged CarePhysician Group ManagementMulti-Specialty PracticesCredentialing Leadership
About the role
Key responsibilities & impact- Manage provider credentialing and re-credentialing
- Understand payer credentialing and identify and resolve complex claims issues
- Work with the National Director of Credentialing to define departmental processes and execute strategic initiatives
- Communicate high-level issues to leadership and remove barriers to progress and implementation
- Liaise between operations, onboarding, Conifer/RCM, managed care, and health plan partners
- Diagnose and resolve claims issues and educate stakeholders
- Oversee credentialing worklists and metrics across Athena and other platforms
- Manage day-to-day relationships and ensure team timelines and Revenue Cycle KPIs are met
- Manage and retrain staff when performance metrics are not met
- Define SOPs for credentialing/claims collaboration, issue resolution, and workflows
- Perform root-cause analysis to resolve claims payment and payment access issues
- Produce and present productivity reports and discuss mitigation plans through resolution
- Elevate health plan relationships and represent TPR physicians with national leaders at major payors
- Provide direct management for reports
- Prioritize credentialing-related RCM issues through resolution before claims become inactive
- Drive claims projects to successful closure and payment
- Support onboarding and acquisition strategies through accurate data submissions and timely project completion
- Lead initial and ongoing team training
Requirements
What you’ll need- Excellent analytical abilities and communication skills
- Experience in progressive health care management, emphasizing health plan/provider contracting and physician group management/contracting
- In-depth knowledge of health plan and governmental payer credentialing, enrollment, medical claims payment and requirements
- Ability to work within a deadline-intense environment
- Demonstrated problem-solving and customer service skills
- Knowledge of primary source verification, provider enrollment, and NCQA credentialing requirements
- Proficient working knowledge of Echo or other credentialing systems
- Proficient working knowledge of Athena
- Proficient working knowledge of Microsoft Office Suite, including Word, Excel, Project, and PowerPoint
- Experience with multi-specialty or large group practices across multiple states/Tax IDs preferred
- Bachelor's degree in healthcare management, public health, accounting, finance, business, social or behavioral sciences preferred or equivalent experience
- 7-10 years of previous managed care experience
- 5+ years' experience in a credentialing leadership role
Benefits
Comp & perks- Resources, tools and support to serve patients and customers
- Career pathway development opportunities
- Support to maximize potential