The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer. Principal Duties and Responsibilities Provides clinical oversight of the contract with the Clinically Responsible Service Providers (CRSP) and clinical oversight on the implementation of physical and behavioral health integration across the DWIHN provider network. Develops policies and procedures in accordance with MDHHS and DWIHN protocols which facilitates appropriate service delivery and coordination of care between the CRSP and Integrated Care Organizations to persons served across all disability designations. Provides clinical and fiscal oversight of the contract with DWIHN providers by reviewing monthly itemized and detailed budget summary reports to approve all appropriate expenditures. Develops, provides oversight and analyzes clinical reports to determine utilization patterns and trends for individuals receiving services. Provides education and training to the Network and its contractors on policies and procedures included in this role. Identifies and supports evidence-based practice and or best practices implementation across the provider network and ensures fidelity standards are met. Works closely with the DWIHN Access and Call Center to review eligibility criteria for services and disability designations and to facilitate referral and coordination with the CRSP. Works in collaboration with the DWIHN Quality Department on policy and procedure necessary for network adequacy. Works in collaboration with the DWIHN Quality department to develop Performance Improvement Plans (PIP) for audits and accreditation (HSAG, NCQA). Works in collaboration with the DWIHN-Integrated Health team regarding physical health integration initiatives impacting the DWIHN provider network. Works in collaboration with the Customer Services department and provider network to resolve member related satisfaction issues. Works with Recipient Rights on grievances, appeals and denial related issues when needed. Conducts regular meetings and community forums for stakeholders and persons served to provide education, training, and updated information regarding policies and procedures specific to the contracted provider network. Works collaboratively with the Adult Initiatives Director to address satisfaction of persons served with regard to service delivery. Ensures data submitted by the CRSP follows the Health Insurance Portability and Accountability Act (HIPPA). Provides technical assistance and monitoring to the CRSP specific to access and coordination of services. Coordinates monthly meetings with CRSP to ensure appropriate utilization and reporting of services. Develops and analyzes clinical reports for persons served to determine patterns and trends and to develop plans of action for providers who do not meet required standards. Serves as part of a multi-disciplinary team to ensure beneficiaries receive the appropriate service provisions based on the clinically appropriate level of care. Provides oversight of the adult I/DD provider network. Ensures that clinical practices and outcomes are being monitored and that DWIHN is in compliance with the MDHHS HAB Waiver clinical audit. Performs related duties as assigned. Knowledge, Skills and Abilities (KSA’s) Knowledge of DWIHN policies, procedures and practices. Knowledge of the DWIHN provider network and community resources. Knowledge of the Michigan Mental Health Code. Knowledge of MDHHS policies, rules, regulations and procedures. Knowledge of medical and behavioral health practices and terminology. Knowledge of compliance standards. Knowledge of documents/regulations that govern the provision of mental health services, e.g., Medicaid Manual Mental Health and Substance Abuse Chapter III, State Plan for Medicaid, Michigan Department of Health and Human Services Quality Plan, BBA requirements and the Mental Health Code. Knowledge of the practices and principles of psychological, emotional, and sociological assessment and diagnosis. Knowledge of regulatory and industry best practice standards. Knowledge of Community Mental Health Services Programs (CMHSP) and Prepaid Inpatient Health Plans (PIHP). Knowledge of Integrated Care practices and principles. Knowledge of and ability to use multiple technology systems. Knowledge of HAB Waiver and HAB Waiver requirements. Knowledge of the adult I/DD provider network. Knowledge of the continuum of care for all disability designations (I/DD SED, SMI, Co-Occurring Disorder). Computer skills. Time management skills. Organizational skills. Critical thinking skills. Teamwork skills. Conflict Resolution skills. Problem-Solving skills. Decision Making skills. Negotiation skills. Project Management skills. Assessment skills. Report writing skills. Communication skills. Multitasking skills. Analytical skills. Adaptability skills. Interpersonal skills. Ability to communicate orally. Ability to communicate in writing. Ability to work effectively with others. Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population. Judgement/Reasoning ability. Working Conditions Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval. This description is not intended to be a complete statement of job content, rather to act as the essential functions performed. Management retains the discretion to add or change the position at any time. Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process.
Credentialing Specialist
Location
United States
Posted
3 days ago
Salary
0
Seniority
Mid Level
No structured requirement data.
Job Description
Credentialing Specialist
DETROIT WAYNE Integrated HEALTH Network
Role Description Under the general supervision of the Director of Managed Care Operations and the direct supervision of the Credentialing Administrator, the Credentialing and Impaneling Specialist performs tasks to ensure that all DWIHN practitioners and provider organizations are credentialed prior to performing services in the DWIHN system. The Credentialing Specialist also ensures healthcare professionals and facilities meet all established federal and state standards, as well as NCQA (National Committee for Quality Assurance) standards. - Completes review of provider credentialing and re-credentialing applications checking for completeness and accuracy. - Prepares reports for the Credentialing Committee on provider file status. - Completes National Practitioner Database Check, Systems for Award Management database check, MDHHS Sanctioned Providers List, and OIG checks as appropriate. - Maintains, tracks and monitors the expiration dates of SAM Registration, accreditation, and license expiration and notifies providers as needed. - Manages the Credentialing process using the Medversant system. - Serves as the primary contact for the Managed Care Operations unit for Medversant and other Credentialing provider inquiries. - Provides instruction and training to the DWIHN Provider Network on the Credentialing process. - Responds to all Provider Requests for new applications and questions regarding the Credentialing process. - Provides status updates for providers and practitioners. - Assists in updating policies and procedures for the Credentialing process. - Completes Readiness Reviews of Providers upon request. - Maintains database of approved services to determine the capacity of the Provider Network. - Prepares and sends approval letters to providers. - Collects and processes verification and accreditation information. - Updates and maintains accurate databases for facilities and practitioners. - Attends Credentialing Committee, subcommittee and other meetings. - Maintains confidentiality of all Provider/ practitioner information. - Performs related duties as assigned. Qualifications - Knowledge of DWIHN policies, procedures and practices. - Knowledge of the DWIHN provider network and community resources. - Knowledge of the Michigan Mental Health Code. - Knowledge of MDHHS policies, rules, regulations and procedures. - Knowledge of Federal policies, rules, regulations and procedures as it relates to DWIHN. - Knowledge of Credentialing principles and practices. - Knowledge of the Medversant software system. - Knowledge of MHWIN. - Knowledge of compliance standards. - Knowledge of NCQA requirements and the accreditation process. - Assessment skills. - Evaluation skills. - Organizational skills. - Interpersonal skills. - Communication skills. - Computer skills (Word, Excel, Access, Power Point, Outlook, Teams). - Teamwork skills. - Ability to communicate orally. - Ability to communicate in writing. - Ability to work effectively with others. - Ability to work with an ethnically, linguistically, culturally, economically and socially diverse population. - Judgement/Reasoning ability. Requirements - A High School Diploma, a GED or its equivalent. - Four (4) years of full-time paid professional experience performing administrative duties and responsibilities. - One (1) year of full-time paid professional experience performing credentialing and impaneling duties and responsibilities. - A valid State of Michigan Driver’s License with a safe and acceptable driving record. - Certified Provider Credentialing Specialist (CPCS) certification is preferred, not required. Working Conditions Work is usually performed in an office setting but requires the employee to drive to different sites throughout Wayne County and the State of Michigan. This position can work remotely with supervisory approval. Please Note: DWIHN requires proof of being fully vaccinated for COVID-19 as a condition of employment. Medical or religious accommodations or other exemptions that may be required by law, will be approved when properly supported. Further information will be provided during the recruitment process. The Detroit Wayne Integrated Health Network is an Equal Opportunity Employer.
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SCM Services d’assurancesWe welcome and encourage applications from people with disabilities. Accommodation is available on request for candidates throughout the recruitment and assessment process. We will not accept unsolicited resume submittals from third-party recruiters and hereby request agencies not to contact our employees or managers directly to present candidates. We welcome resumes submitted directly from candidates.
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