Job Details

Responsible for the comprehensive management and integrity of the organization's provider credentialing data and systems. This role ensures strict compliance with regulatory standards, including NCQA requirements, by maintaining accurate provider information, preparing essential reports and delegated payer rosters, and coordinating all internal and external payer audits. Key responsibilities also include managing system upgrades and testing, responding to payer inquiries, developing custom report queries for leadership, and ensuring the confidentiality and integrity of all credentialing information.

Job Description

Job Summary:

Responsible for the comprehensive management and integrity of the organization's provider credentialing data and systems. This role ensures strict compliance with regulatory standards, including NCQA requirements, by maintaining accurate provider information, preparing essential reports and delegated payer rosters, and coordinating all internal and external payer audits. Key responsibilities also include managing system upgrades and testing, responding to payer inquiries, developing custom report queries for leadership, and ensuring the confidentiality and integrity of all credentialing information.

Essential Functions:

• Interacts with co-workers, visitors, and other staff consistent with the values of Jefferson.

System and Data Management:

• Manage and maintain the integrity of all system elements and data within the credentialing software (ECHO and CACTUS). Make recommendations for improving reporting and processes.

• Distribute reports related to upcoming expirables and ensure the system is accurately updated and maintained.

• Design, create, and execute custom data queries for both the ECHO and CACTUS credentialing systems to support internal reporting needs, leadership inquiries, and staff requests.

• Generate and manage routine and custom reports, specifically for payer rosters.

• Ensure that all departmental policies and procedures strictly adhere to current National Committee for Quality Assurance (NCQA) standards and other applicable regulatory requirements.

• Manage and coordinate the processes and workflows of data coordinators when applicable, ensuring efficient and accurate data handling practices.

Minimum Education and Experience Requirements:

Education:

Minimum Bachelor’s degree preferred

AND/OR

Experience:

• Proven experience developing and documenting technical business requirements for system enhancements or reports inclusive of data management 3-5 years of experience in a healthcare setting, ideally within credentialing, provider data management, or a related compliance/auditing role.
• Knowledge of NCQA requirements.

Work Shift

Workday Day (United States of America)

Worker Sub Type

Regular

Employee Entity

Thomas Jefferson University Hospitals, Inc.

Primary Location Address

1101 Market, Philadelphia, Pennsylvania, United States of America

Nationally ranked, Jefferson, which is principally located in the greater Philadelphia region, Lehigh Valley and Northeastern Pennsylvania and southern New Jersey, is reimagining health care and higher education to create unparalleled value. Jefferson is more than 65,000 people strong, dedicated to providing the highest-quality, compassionate clinical care for patients; making our communities healthier and stronger; preparing tomorrow's professional leaders for 21st-century careers; and creating new knowledge through basic/programmatic, clinical and applied research. Thomas Jefferson University, home of Sidney Kimmel Medical College, Jefferson College of Nursing, and the Kanbar College of Design, Engineering and Commerce, dates back to 1824 and today comprises 10 colleges and three schools offering 200+ undergraduate and graduate programs to more than 8,300 students. Jefferson Health, nationally ranked as one of the top 15 not-for-profit health care systems in the country and the largest provider in the Philadelphia and Lehigh Valley areas, serves patients through millions of encounters each year at 32 hospitals campuses and more than 700 outpatient and urgent care locations throughout the region. Jefferson Health Plans is a not-for-profit managed health care organization providing a broad range of health coverage options in Pennsylvania and New Jersey for more than 35 years.    

Jefferson is committed to providing equal educa­tional and employment opportunities for all persons without regard to age, race, color, religion, creed, sexual orientation, gender, gender identity, marital status, pregnancy, national origin, ancestry, citizenship, military status, veteran status, handicap or disability or any other protected group or status. 

Benefits

Jefferson offers a comprehensive package of benefits for full-time and part-time colleagues, including medical (including prescription), supplemental insurance, dental, vision, life and AD&D insurance, short- and long-term disability, flexible spending accounts, retirement plans, tuition assistance, as well as voluntary benefits, which provide colleagues with access to group rates on insurance and discounts. Colleagues have access to tuition discounts at Thomas Jefferson University after one year of full time service or two years of part time service. All colleagues, including those who work less than part-time (including per diem colleagues, adjunct faculty, and Jeff Temps), have access to medical (including prescription) insurance.

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