MANAGER, PROVIDER RELATIONS, ENROLLMENTS, DELEGATED CREDENTIALING & CLAIMS ADMIN

FLSA Status

Job Role Summary

The Manager, Billing Integrity & Provider Relations is responsible for leadership, management and oversight of credentialing and enrollment of all Eskenazi Locations including the hospital, inpatient psych unit, outpatient departments (on and off campus), the SEMHC Community Mental Center (CMHC) and Federally Qualified Health Centers (FQHC), Independent Diagnostic Testing Facility (IDTF) as well as all providers (including physicians, nurse practitioners, and other eligible practitioners with Medicare, Medicaid, Medicare Advantage and Medicaid Managed Care Entities and ensuring compliance with all laws, rules, regulations, and payor specific guidelines as well as NCQA.  The manager is responsible for researching legal requirements and payor guidelines and analyzing complex issues and provide guidance and mitigation strategies, including overseeing development and implementation of claim edits and logic, related to healthcare operational issues impacting billing and reimbursement by working with internal EPIC partners as well as vendors. The manager works collaboratively with senior leadership, legal, compliance and operational leaders throughout the organization as well as outside counsel to ensure the integrity of claims submitted to payors for reimbursement are compliant with all requirements including identification and application of unique requirements for IDTF, FQHC, and SEMHC CMHC locations and others as applicable.

Essential Functions and Responsibilities

• Manages provider relations, delegated credentialing, enrollment, provider panel management and claims administration staff and functions to ensure productivity and quality standards are met and to develop processes, workflows, as well as staff development, performance management, hiring, firing, promotion, transfer, and disciplinary action.
• Develop and manage provider enrollment and delegated credentialing workflows to ensure timely enrollment and revalidation of locations and providers with Medicare, Medicaid, out of state Medicaid vendor and all contracted payors to ensure maximum revenue capture and reduce denials and adjustments related to provider enrollment, credentialing, and related functions.
• Develop and manage claims administration and project management functions including electronic transmission of HIPAA Transactions between EPIC, clearinghouses and payors, ensuring ongoing timely escalation of issues impacting AR, cash posting, EPIC Contract Manager, staff access to clearinghouses and various payor sites as well as collaborating with outside vendors and internal stakeholders to identify  software improvement opportunities to support billing and appropriate revenue capture.Develop, manage, and oversee all processes related to payor provider directories and timely revalidation, and accuracy of the information published in compliance with payor requirements and NCQA guidelines.
• Maintains current knowledge of all Federal and State Laws, Regulations and Payor requirements specific to claims presentation, billing, reimbursement, and provider enrollment and applies this knowledge by interpreting and applying to complex issues, conflicting laws, rules, and regulations, related to the operational structure, claim submission and reimbursement for services rendered and other related areas.
• Collaborates with operational leaders, revenue cycle, compliance, legal and outside counsel  regarding various issues related to provision of services and provider types, ensuring claims presented to payors are in compliance with all applicable laws ,regulations, guidelines, and recommends corrective action plans when needed.
• Collaborates with Vendors (EEG, etc.), IU Health legal, provider enrollment and others to ensure providers are enrolled and charges are billed appropriately based on the contractual agreements and lease of capacity arrangements. 
• Provide guidance to operational areas in areas related to compliance
• Manages processes and communications for the Delegated Credentialing Committee (consisting of physicians, nurse practitioners and other qualified provider types) required by NCQA and Delegated Payor contracts.  This Committee is responsible for reviewing all payor credentialing and recredentialing files and either approving the file or implementing corrective action plans as required by the contracts to permit billing of services rendered by providers.
• Develop, Manage, and oversee the Provider Relations Committee which is responsible for collaboration with all operational clinical managers/leaders, EPIC team, Access & Provisioning, and others to establish processes to ensure timely credentialing and enrollment of providers in support of operational needs ensure providers can bill for services rendered, ensuring appropriate and timely revenue capture.
• Collaborates with the Director of Managed and Value Based Care by reviewing contracts related to claims, billing, delegated credentialing claims and recommending updates to ensure related processes and workflows are compliant with all laws and regulations as well as NCQA guidelines
• Manages development and implementation of requests for EPIC and FinThrive edits and logic updates to ensure compliance with all Federal and State Laws, regulations, and payor guidance

Job Requirements

• Bachelor's degree required in Health Information Administration, Healthcare Administration, or RHIA preferred.  
• In lieu of degree must have 10 years of experience in healthcare compliance, legal, billing, coding, auditing, or related comparable experience.   

Knowledge, Skills & Abilities

• Knowledge of Federal and State laws and regulations related to healthcare including billing and reimbursement in all areas of operation including acute care hospital, inpatient psychiatry, hospital outpatient, community mental health center, Federally Qualified Health Center, and Independent Diagnostic Testing Facility each of which has specific and unique requirements
• Knowledge of Medicare, Medicaid, and commercial payor regulations specific to provider enrollment, credentialing, claims submission, reimbursement
• Knowledge of NCQA guidelines required for payor credentialing
• Knowledge and ability to work with various databases including CMS Identity and Access, CMS data.gov, NPPES, PECOS, CAQH, and sites requires for primary source verification of provider credentialing (Indiana license verification, NPDB, OIG exclusions database, Indiana Medicaid, and provider credentialing and enrollment software and payor portals.
• Knowledge of HRSA requirements including UDS
• Knowledge of PFAC requirements and providers reports required to obtain reimbursement
• Demonstrates effective and appropriate critical thinking skills and decision-making abilities 
• Demonstrates strong leadership, interpersonal, and problem-solving skills, and the ability to provide clear direction to others
• Demonstrates initiative, self-motivation, practical learning skills, enthusiasm, and an ability to prioritize effectively complete multiple tasks in a timely and accurate manner 
• Demonstrates proven ability to work with all levels and to communicate clearly, efficiently, and professionally
• Demonstrates professional and effective verbal and written communication skills
• Expert knowledge, skills and ability related to creating and analyzing reports from EPIC, FinThrive and other sources; performing complex analysis in Excel using critical thinking skills and analytical tools such as VLOOKUPS, Pivot Tables and the ability to learn new software applications quickly including the ability run reports/queries.