Lead Credentialing Specialist

The Lead Credentialing Specialist is responsible for the entire medical credentialing, payer credentialing, and licensure process, ensuring the organization remains in compliance with all credentialing rules and requirements set internally by Affiliates Risk Management Services (ARMS) and Planned Parenthood Federation of America (PPFA) and, by state and federal regulatory agencies, and third-party payers. This role will report to the Manager of Billing and Credentialing. 

1. Supervise the Credentialing Specialist once the position has been filled.

2. Ensure licensed providers are credentialed so they can continue to support the provision of all healthcare services we offer including abortion. 

3. Oversight of credentialing in accordance with Planned Parenthood of Illinois (PPIL), PPFA and legal standards. 

4. Create, update, and maintain credentialing packets through the Certified Verification Organization (CVO), as applicable, to collect all current required data required within the applicable governing regulations, and support onboarding providers through the credentialing process. 

5. Submit and track payer applications with strict adherence to procedure and deadlines, monitor applications, and follow up as needed. 

6. Perform primary source verifications for provider onboarding in a timely manner that upholds NCQA, PPFA, ARMS, and payer standards. 

7. Measure and track credentialing costs and communicate costs and procedure updates with the supervisor. 

Collaboration with Internal and External Partners: 

1. Maintain strong working relationships with internal and external partners and manage the improvement, functionality, and rapport with account reps from the CVO. 

2. Build and maintain relationships with payer contracts to improve payer application processes and minimize credentialing related write-offs and expenses. 

3. Work closely with payer contacts and PPIL Payer Verification teams proactively to address network participation issues. 

4. Communicate and strategize with Health Center Operations, Human Resources & Talent, and Risk, Quality Management & Patient Safety regarding onboarding and current providers’ credentialing statuses and ensure credentialing process remains on track according to deadlines and expectations. 

The Lead Credentialing Specialist is responsible for maintaining and designing efficient processes, and meticulously organizing data to ensure department operations, regulatory compliance, and audits are efficient. For optimum efficiency, this role will: 

1. Implement a checks and balances system to improve performance. 

2. Run monthly reports on credentialing trends, data, delays & performance, and flag suspicious verifications to appropriate parties. 

3. Conduct briefs, address hurdles, and collaborate with credentialing team on obstacles. 

4. Perform yearly audit of credentialing applications, verifications, licensure, provider liability insurance, and miscellaneous credentialing paperwork is received, tracked, and filled appropriately. 

5. Identify administrative deficiencies, implement improvements, and set yearly departmental goals. 

6. Manage the credentialing section of PPFA accreditation process. 

1. Demonstrate an understanding of and commitment to remain informed about PPIL protocols, policies, and procedures. 

2. Demonstrate an understanding of and commitment to PPIL core values of access, activism, care, confidentiality, diversity, excellence, integrity, respect, self-determination, and stewardship; practice these values in relations with internal and external customers. 

3. Other duties as assigned. 

Physical demands/Work Environment: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform these essential functions. While performing the duties of this job, the employee is regularly required to sit, stand, walk, talk, hear and use the phone. The employee is frequently required to use hands and fingers to key in data, handle, or feel and reach. This is a hybrid role where the employee will work remotely and in person at an administrative office. The employee may occasionally lift and/or move up to 25 pounds. 

Supervisor: Manager of Billing and Credentialing

Status: Full Time, Non-Exempt from the overtime provisions of the wage and salary regulations. 

Qualifications: 

Associate's degree or equivalent combination of experience and education preferred. High School Diploma or GED Required. Certification in Credentialing is preferred. 

Strong knowledge of Commercial, Medicaid/MCO Insurances. Minimum of 2 years of relevant credentialing and healthcare practice experience. Ability to demonstrate working knowledge of health care credentialing and denials processes, including a thorough understanding of medical insurance carrier policies and procedures, State and Federal rules and regulations. Technology skills must include expertise in use of spreadsheet software and electronic records systems. Project management and database management skills desired. 

This role requires a proactive problem-solver with strong analytic and interpersonal skills that 

include: 

• Excellent follow-through and attention to detail 

• Ability to proactively prioritize and attend to detail 

• Excellent interpersonal relationship management skills 

• Strong communication, written and oral, and excellent organizational skills 

• Ability to work under pressure and meet stringent deadlines, in a fast-paced environment 

• Commitment to maintaining confidential information 

Planned Parenthood works affirmatively to include diversity among its workforce and does not discriminate in the selection of its staff based on factors including but not limited to race, color, religion, sex, national origin, age, sexual orientation, gender identity, disability, income, marital status or any other characteristic protected under federal, state or local law. We know that BIPOC and women identifying candidates are less likely to apply to jobs unless they meet every requirement. Please do not be deterred if your past experience doesn’t align perfectly with every qualification in the job posting.