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Position in this function is responsible for leading all aspects of credentialing and provider enrollment for an Optum Care Delivery Organization. Effectively communicate with local markets, leadership, and functional business teams to achieve operational efficiencies and foster a proactive and highly responsive provider-centric operating model.

Hybrid role. 3 days a week in the office

Primary Responsibilities:

• Credentialing activities including initiation and review of application, primary source verification, processing provider enrollments, re-enrollments and demographic updates with contracted payers, and ongoing monitoring of credentials

• Managing a team of credentialing professionals and is accountable for systems and processes that ensure compliance with organizational credentialing policies and procedures, and compliance with the credentialing requirements of our health plan partners, and related regulatory and accrediting agency requirements

• Assist in the development and administration of policies and procedures related to credentialing activities

• Set team direction, develop proactive goals and measure team performance against operational targets

• Use pertinent data and facts to identify and solve a range of problems within area of expertise, and provide guidance to team on non-standard requests

• Oversee the tracking and maintenance of all provider data in provider data management system, ensuring high quality standards are maintained

• Oversees initial applications and reappointments for Medicare / Medicaid enrollment, hospitals, surgical centers and managed care entities for assigned divisions

• Conduct ongoing training on credentialing and enrollment procedures for the PAC West/MW Region

• Consult with internal and/or external stakeholders to address business needs and reduce operational challenges

• Monitors external credential databases, including CAQH, PECOS and other regulatory agencies, to ensure data is updated and ready for quick retrieval and use by interested parties

• Ensure credentialing files are complete before presentation to Credentialing Committee

• Provide consultation to Credentialing Committee / leadership on issues related to consideration of clinician credentials and reappointments

• Oversee compliance with health plan requirements related to sub- delegated credentialing agreements and credentialing file audits

• Oversee processes and reviews (including ensuring resolution) all reports related to adverse actions such as sanctions, licensure actions or limitations, and credentialing-related complaints

• Interview, hire and train new staff on credentialing and recredentialing policies and procedures; also provides ongoing training as needed regarding new guidelines or updated processes / policies

• Daily monitoring of employee’s workload and various credentialing work streams (e.g. onboarding, credentialing, pharmacy, medical staff privileging, Medicare/Medicaid enrollments, Credentialing Committee meetings, health plan enrollments, etc.)

• Play an important role in making decisions regarding employee’s performance issues such as the need for disciplinary counseling, performance documentation, etc.

• Conducts periodic audits of credentialing files and staff work-product

• Conduct audits and provide feedback to reduce errors and improve processes and performance

• Oversees work activities of other supervisor(s)

• TIN changes, TIN consolidations across MW region

• M & A credentialing review and analysis

• CHOW with CMS

• Claim denial analysis

Other responsibilities may include:

• Monitor renewals of licensure and other documents subject to expiration, and ensures updates are forwarded to facilities and healthcare partners as renewals are received

• Oversee and coordinate CMS site visits

• Work with leadership to identify and implement best practices related to credentialing and enrollment

• Responds to facilities and health plan inquiries, interfaces with internal staff and external customers on day-to-day credentialing/enrollment issues

• Collaborates with leadership on submitting and maintaining up-to-date health plan rosters

• Responsible for management and supervision of credentialing staff / team

• Upon request of supervisor, attends meetings with payer representatives to address outstanding issues

• Respond to internal / external request for credentialing and licensing status

• Develop reports to present to the leadership staff as requested

• Other activities as outlined in the credentialing and recredentialing policies and procedures

• Other duties as assigned and modified at manager’s discretion

You’ll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• 4+ years credentialing/payer enrollment experience

• 3+ years supervisory/leadership experience

• Healthcare and Managed Care experience

• Government and commercial payer enrollment knowledge; group and individual level

• Knowledge of credentialing procedures, policies, and terminology (i.e., NCQA, CMS, AAAHC, JC, URAC)

Preferred Qualifications :

• Experience leading cross-functional team(s) to achieve operational goals

• Proven excellent written and verbal communication

• Proven ability to effectively prioritize and execute tasks in a high-pressure environment

Nevada Residents Only: The salary range for this role is $70,200 to $137,800 annually. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you’ll find a far-reaching choice of benefits and incentives.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone–of every race, gender, sexuality, age, location and income–deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes — an enterprise priority reflected in our mission .

Diversity creates a healthier atmosphere: OptumCare and its affiliated medical practices are Equal Employment Opportunity/Affirmative Action employers and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

OptumCare and its affiliated medical practices is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.