Sr. Manager, Peer Review and Credentialing / Job Req 1040495936

Hybrid role: External applicants must be a California resident as of their first day of employment.Internal applicants must live in their current approved state (The 6 approved states: CA, AZ, NV, TX, WA, OR).

PRINCIPAL RESPONSIBILITIES: Under the supervision of the Executive Director Network Operations, the Sr.

Manager, Peer Review and Credentialing is responsible for oversight and administrative management of the Alameda Alliance credentialing process for physicians, allied health practitioners, ancillary practitioners and organizational providers.

The position is also reponsible for the supervision of peer review and credentialing staff and credentialing vendors.

Addtionally, this position provides credentialing oversight of the delegated entities.

The function of Peer Review and Credentialing is to support compliance with NCQA, CMS, DHCS, DMHC, and other regulatory agencies relative to all functions of credentialing.

Principal responsibilities include: Manage oversight and supervision of credentialing and peer review staff to ensure compliance and timely processing of new provider and recredentialing applications.Primary resource in credentialing, quality assurance/performance improvement credentialing requirements, and department and committee activities.Maximize the credentialing and peer review teams efficiency, productivity, and performance by keeping employees accountable for meeting credentialing guidelines.Manages the credentialing vendors including Cactus, CVO, and CAQH services.

Conducts audits on all reports and files to ensure compliance, reviews invoices for their accuracy, and approves payment.

Implement Corrective Action Plans when required.Perform periodic file audits to ensure that credentialing procedures meet regulatory requirements and Alliance standards, and credentialing files are complete.Manages ongoing reporting process that is accurate, timely, and action driven that support the credentialing staff.Collaborate with the Chief Medical Officer to ensure that all significant malpractice cases, state/federal sanctions, and quality issues are reviewed prior to peer review.Manage ongoing monitoring as required by regulatory agencies.Interpretes, develops, and implements practices of all credentialing systems and functions to ensure continuous compliance with applicable regulatory agencies and accrediting bodies, e.g., NCQA, DMHC, DHCS, CMS, etcPerform delegated entity annual credentialing audits and review quarterly credentialing reports as required by regulatory agencies.

Implement Corrective Action Plans as required.

Summarize and submit reports to CMO and Compliance Department as requested.Primary contact for internal credentialing audits as required.

Act as a resource on credentialing regulatory requirements.Responsible for coordination and submission of the Peer Review and Credentialing Committee including coordination auditing files and preparation of materials, preparation of agenda, and conduct follow up from Peer...