Supervisor Payer Enrollment & Reporting

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This position functions in a complex payer credentialing environment with changing health care rules, regulations and laws under the leadership of the Director of Professional Services. This position oversees all aspects of the centralized payer reporting and enrollment processes, including facility and provider onboarding, revalidations and delegated reporting oversight for approximately 13 Hospitals and over 2,600 physicians and allied health practitioners for Health Partners Network, Inc. (PHO), Integrated Health System and West Virginia United Health Systems. Interfaces with the HPN/WVUIS Manager, Professional Services, Director, Professional Services and VP, Payer Strategy & Contracting as well as hiring Recruiters, Managers, Administrators and VPs to provide and interpret relevant data enabling identification of facilities and practitioners who may or may not meet the standards required for enrollment with payers. Extensive knowledge in the area of the Director of Professional Services’ area(s) of administrative responsibility is required in order to relieve superior of certain responsibilities.

MINIMUM QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. High School Diploma or GED required

EXPERIENCE:

1. Five years in managed care, physician’s office practice or credentialing office

2. Seven years of health care industry experience

PREFERRED QUALIFICATIONS:

EDUCATION, CERTIFICATION, AND/OR LICENSURE:

1. Bachelor’s Degree preferred

EXPERIENCE:

1. Two years of supervisory experience

CORE DUTIES AND RESPONSIBILITIES: The statements described here are intended to describe the general nature of work being performed by people assigned to this position.  They are not intended to be constructed as an all-inclusive list of all responsibilities and duties.  Other duties may be assigned.

1. Supervises enrollment and reporting staff and carries our supervisory responsibilities that may include but are not limited to: interviewing, hiring, firing, counseling, disciplinary actions, annual performance reviews, training, planning, assigning and directing work, addressing complaints and resolving problems.  Must make sound business decisions while maintaining sensitivity to staff needs and concerns.

2. Assist with the development of productivity standards for staff. Assist with the development of reports to track staff productivity.  Evaluate and redistribute workload of staff members when necessary to ensure maximum productivity.

3. Assist in development of processes and work flows to ensure timely completion of facility/provider enrollments and payer reporting. 

4. Supervise the work flows and operations of the enrollment staff in completing, submitting and tracking of facility and provider applications for West Virginia United Health System while ensuring timely follow-up.

5. Advises the Director of Professional Services of any problems or perceived problems with providers enrollment applications, facilities applications or breakdowns in the application process flows.  Then notifies hiring administrator and/or VP as appropriate.

6. Demonstrates expertise in understanding of NCQA, TJC, CMS and state regulations as it relates to the enrollment processes.

7. Research and analysis of current enrollment requirements to ensure of all documentation is submitted in compliance with policies, regulatory requirements and accreditation standards.

8. Responsible for the maintenance and integrity of the credentials data base and works closely with IT and our software vendor to resolve issues.

9. Oversee the creation and preparation of reports including, but not limited to:  HPN rosters, ASO reports, monthly provider profiles/rosters, weekly staff meeting reports, etc.

10. Supervise the work flows and operations of the payer reporting staff in creating, submitting and tracking monthly system wide enrolled provider reports for compliance and revenue cycle operations for West Virginia United Health System. 

11. Ensures payer reporting compliance for more than 20 payers who have delegated credentialing to West Virginia University Hospitals Inc., West Virginia United Insurance Services Inc. and Health Partners Network, Inc.

12. Develop and maintain service benchmarks and quality improvement programs.

13.Communicates with payers to resolve authorization and billing denials related to the facility and/or provider(s) not being loaded as participating.

14. Consistently ensures a customer service orientation with regard to requests, customer problems, complaints, suggestions, etc., follows through with and/or resolves while presenting an image of professionalism.

15. Actively seeks to promote and helps maintain interactions with others inside and outside the organization in a positive, professional, team-oriented, and service-conscious environment which contributes to the goals of the organization and reflects the values of the System.

16. Works effectively, confidently and pro-actively with others in the Department, Medical Staff Leaders, Hospital Administrators, Office Managers, Billing Managers and other personnel and customers.

17. Nurtures an atmosphere of collaboration and team oriented interpersonal relationships, communication flow and information sharing between departments

18. Demonstrates a respect for the human dignity of all individuals (employees, physicians, peers, volunteers, customers, visitors, etc.); helps to create and maintain team work within the work environment; practices good negotiation skills for resolving conflicts under time pressures and deadline commitments

19. Maintains proper attendance and punctuality to ensure continuity in the functions of the position.

20. Maintains a high level of confidentiality in all aspects of the position

PHYSICAL REQUIREMENTS: 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 the essential functions.

WORKING ENVIRONMENT: The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

1. Standard office environment.

SKILLS AND ABILITIES:

1. Ability to work extended hours as needed.

2. Analytical and problem-solving skills with excellent attention to detail.

3. Ability to function in a demanding and fast paced environment.

4. Possess excellent organizational and prioritization skills and have the ability to work on several projects simultaneously.

5. Ability to carry out a range of functions: organize, delegate, direct, and review the work of others; maintain an effective work pace under deadlines; learn and apply pertinent statutory provisions, rules, regulations, policies, procedures; read and understand manuals and other detailed books of instruction; create action plans for special projects; and manage the implementation process through completion.

6. Proficient computer skills, thorough knowledge and understanding of office software programs including Windows, MS Office, Excel, Outlook and ability to create, update and run reports in the credentialing database (ECHO) or similar applications.

7. Knowledge of URAC, NCQA, and TJC(if applicable) standards

8. Possess excellent communication skills in order to communicate with influential internal and external contacts.

Additional Job Description:

Scheduled Weekly Hours:

40

Shift:

Exempt/Non-Exempt:

United States of America (Exempt)

Company:

SYSTEM West Virginia University Health System

Cost Center:

649 SYSTEM Managed Care and Payer Relations