Payor Relations & Credentialing Manager

About FCHC:

Since 1976, Florida Community Health Centers, Inc. (FCHC) has been a health care leader in Florida. We provide comprehensive primary and specialty health care and patient support services through a network of Centers surrounding Lake Okeechobee and across Florida’s Treasure Coast. Our mission is to ensure that everyone in our communities has access to culturally competent, high-quality health care that they can afford. FCHC has locations in Clewiston, Moore Haven, Okeechobee, Fort Pierce, Port St. Lucie, Stuart, Indiantown, Pahokee and West Palm Beach. FCHC’s Corporate Office is centrally located in West Palm Beach, Florida. FCHC has multiple staff members who speak Spanish and Creole, and translation is available for other languages as needed. FCHC has created a “one-stop shop” for patients–providing Pediatric and Adult Primary Care, Dental, OB/GYN and Women’s Health, Infectious Disease, Behavioral Health, Pharmacy, chronic disease education and care management, referral assistance, benefit enrollment assistance and coordination, and telehealth services. Our patients benefit from a “medical home” model, where they may access our extensive array of health care clinicians and services in an atmosphere where they are treated with respect, care, and concern.

Mission

The Mission of Florida Community Health Centers, Inc. (FCHC) is to provide accessible, cost-effective, high-quality, comprehensive health care to all persons in our communities.

Vision

Florida Community Health Centers, Inc. (FCHC) will maintain strong leadership in, and advocate for, the provision of health care services.

FCHC will foster and promote collaborative relationships and will develop partnerships with local, state, and federal public health service agencies and the community in general, to enhance the quality of delivery systems for comprehensive health care. FCHC will be an employer of choice and will demonstrate excellence with a highly trained staff and governing board.

Values

FCHC values Integrity, Compassion, Commitment to serving others (external and internal to the organization), Innovation, Effectiveness (cost and outcome), Efficiency, being Mission-driven, Commitment to serving others internal to organization and Commitment to Excellence.

Position Summary: The Payors Relation & Credentialing Manager is responsible for overseeing all aspects of Credentialing and Privileging and payor relationships for the organization. Thorough knowledge of current credentialing standards such as Health Resources and Services Administration (HRSA) and The Joint Commission (TJC). In addition to follow FCHC Credentialing Policies and Procedures. The Payors Relation & Credentialing Manager plays an important role in FCHC’s growth in patients, revenue and profitability and in conjunction with Senior Leadership assesses current contract performance data, indication of specific revenue enhancement opportunities and renegotiating contracts to improve financial outcomes.

Roles and Responsiblities:

• Completion of all facilities and health care professionals credentialing and re‐credentialing applications including the privileging and re‐privileging for all Clinicians employed/contracted with Florida Community Health Center, Inc. with all contracted Health Plans.
• Provide consistent and timely follow up on all outstanding credentialing/re‐credentialing files as well as create the credentialing files for the Credentialing Committee.
• Ability to effectively communicate and collaborate via email, telephone, and verbally, with team members including Senior Leadership, other departments, Center Administrators, Clinical Center Administrators, Clinicians, and Insurance Reps. Develops and maintains outstanding relationships with all insurance Representatives considering any issues and concerns.
• Knowledge of Medicare (NGS+FFS), Medicaid, CMS, Commercial, and HMO Payer Provider Enrollment, Rules, Regulations, and Guidelines.
• Coordinate and Retrieve AHCA Level II Background Screenings.
• Responsible for monitoring and managing the clinicians’ information in in the Credentialing Software, Modio Health and manage and maintain CAQH, Medicaid, and Medicare profiles as an organization.
• Responsible for all Provider Terminations with the Payers.
• Answer credentialing telephone line and provide support to all inbound calls.
• Perform quarterly credentialing audits to ensure all Clinicians are credentialed.
• Participate in various education/trainings as required
• Maintain privacy and confidentiality at all times
• Ensure claims are not denied due to non‐credentialing, and work with the payors and the Finance Department in projects to ensure appropriate reimbursement.
• Cross train within department to support credentialing operations (providing back‐up support for telephones, credentialing files, vacation/ETO)
• Create and maintain a contract library to facilitate day to day operations, identify new opportunities and change/update workflows
• Identify all Commercial, Medicare, Medicaid and Exchange Licensed in the FCHC service area
• In conjunction with Senior Leadership and Business Intelligence, create and implement tools to capture, assess and report key managed care and payor data, including but limited to: Plan Lives, encounters, revenue (Capitated and FFS), contractual requirements, incentives payments
• Serve as the FCHC functional expert for each contractual arrangement. This includes understanding of patient attribution, incentive and payment arrangements.
• In conjunction with the COO and Senior leadership implement new Medicare Advantage agreements
• Stay abreast of industry trends through networking with FACHC, HCN and Managed Care leaders in other Health Centers
• Excellent organizational, interpersonal, and follow up skills with attention to detail and accuracy
• Informational research skills
• Ability to organize and prioritize work and manage multiple priorities simultaneously to meet deadline
• Perform other departmental duties as required.

Qualifications and Education Requirements:

• 5+ years if experience in credentialing
• Certified
• Some experience in billing preferred
• Ability to create and improve processes
• CPCS Certified Provider Credentialing Specialist preferred

ADDITIONAL NOTES

THIS JOB DESCRIPTION IS NOT INTENDED TO BE ALL‐INCLUSIVE, AND EMPLOYEE WILL ALSO PERFORM OTHER REASONABLE RELATED BUSINESS DUTIES AS ASSIGNED BY SUPERVISOR.