Job Description

Work Schedule: Monday through Friday, 8:00 AM – 5:00 PM

Work Location: (Onsite) 77 E. Thomas Rd., Phoenix, AZ 85012

Must be flexible to travel to Arizona clinics for state medical audits.

Position Summary:

The Director of Compliance & Credentialing is responsible for developing, implementing, and overseeing MBI’s compliance program to ensure adherence to all applicable federal, state, and local laws, regulations, and industry standards. This role requires a deep understanding of the healthcare industry, including credentialing, coding, billing, healthcare and privacy regulations. The Director of Compliance/Credentialing will collaborate with leadership to foster a culture of compliance and ethical conduct. This position is responsible for working closely with the executive management team to ensure the consistent readiness of all regulatory requirements.

Responsibilities

Compliance Management:

• Proactively reports to and educates the Executive team and the management team regarding regulatory compliance and related issues, new statutes/guidelines.
• Consults with management, medical staff and department directors on compliance issues.
• Develops risk-based compliance testing of existing procedures and controls to identify, detect and correct noncompliance.
• Reviews and analyzes reports in relation to compliance.
• Facilitates work process teams as requested/needed.
• Develop, implement, and maintain a comprehensive compliance program aligned with organizational goals and industry best practices.
• Stay abreast of healthcare laws, regulations, and industry standards to ensure compliance.
• Conduct regular risk assessments to identify potential compliance vulnerabilities.
• Develop and implement policies and procedures to mitigate compliance risks.
• Oversee compliance training and education programs for all employees.
• Conduct internal audits and investigations to assess compliance with laws and regulations.
• Respond to regulatory inquiries and audits in a timely and effective manner.
• Monitor industry trends and emerging compliance challenges.
• Assists staff with developing a systematic approach to data collection, measurement, assessment, and improvement of processes.
• Participates in departmental and association wide informational meetings and in services, including staff meetings, association wide forums, and seminars.
• Reviews department and association wide policies and procedures annually. Develops and maintains new policies and procedures as needed.

Credentialing Management:

• Direct the processing of applications for appointment and clinical privileges in an accurate, thorough and timely manner in accordance with the company’s credentialing policies for medical s
• Directs the payer credentialing operations, including but not limited to CAQH management and payer credentialing applications.
• Directs coordination of data between internal and external systems, including licensures, CAQH and NPPES.
• Develops innovative strategies for improvement to ensure optimal functioning of the department and compliance with all state, federal and regulatory requirements, policies and processes.
• Ensures that the medical staff policies and credentialing procedures are current with state, federal and regulatory requirements and that all processes of credentialing, privileging and medical staff appointment of physicians and relevant licensed independent practitioners are in compliance with the bylaws.
• Reviews, interprets and provides consultation and timely advice to administration regarding regulatory guidelines, including medical staff bylaws and corrective actions.
• Reviews, oversees and advises medical staff leadership and executive management regarding credentialing of providers, recredentialing, and privilege expansion/reduction requests; assesses whether individual providers provide services within the scope of licensure.
• Develops and directs systems and processes for professional practice evaluation of new and existing medical staff members.
• Advises and supports the relevant Medical staff leadership on matters of medical staff credentialing, professional practice evaluation and implementation performance improvement plans.
• Directs the development, enhancement and maintenance of the credentialing database; assures accuracy of data entry; monitors critical data for analysis and coordinates functional report generation.
• Creates a culture of excellence and customer service in all processes with all internal and external customers including current and future members of the medical staff and other providers, clinical and administrative leaders and all external representation.
• Researches information on new types of practitioners and their scope of practice, and scope of practice of existing practitioners.
• Maintains confidential files on all medical staff members. Credentials files reflect current licensure, insurance, and board certification status.
• Assesses and ensures compliance with payer credentialing standards.
• Assesses medical staff compliance with regulatory standards.
• Communicates identified deficiencies with the appropriate medical staff leaders and executive management. Supports corrective action on identified deficiencies as appropriate.
• Performs related duties as assigned.

Minimum Qualifications:

• EDUCATION: Bachelor’s degree in a medical, business, or related field, or an equivalent combination of relevant education and experience. Master’s Degree Preferred.
• EXPERIENCE: At least five (5) years of experience as a medical staff manager or director or a similar position in the medical field preferred and at least one (1) years’ experience in payer credentialing
• LICENSURE OR CERTIFICATION: CPCS, CRCM, CCEP or CPMSM certified, highly preferred.
• Healthcare industry experience, preferably in a compliance or credentialing role

Knowledge, Skills and Abilities:

• Deep understanding of healthcare regulations, including HIPAA, Stark Law, and Medicare/Medicaid guidelines
• Expertise in credentialing standards and processes, such as CAQH
• Strong leadership and project management skills
• Excellent analytical and problem-solving abilities
• Effective communication and interpersonal skills
• Ability to prioritize and manage timelines.
• Ability to complete routine reports and correspondence.
• Ability to listen and accurately interpret others’ communication or instructions to take appropriate action.
• Ability to speak effectively before groups of customers or employees of organization.

Benefits:

At MBI, our commitment to providing accessible and convenient care to individuals injured at work is a team effort. Every employee and role are essential and valued. Rewarding the dedication and commitment of our employees extends beyond a paycheck. In addition to competitive salaries, we offer to full-time employees:

• Group Medical, Dental, and Vision Insurance
• Life, Short-Term, and Long-Term Disability Insurance
• 401(K) with company match
• Generous Paid Time Off
• Colleague Referral Bonus Program

Equal Opportunity Employer

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