At Houston Methodist, the Senior Managed Care Credentialing Specialist is responsible for leading and executing complex credentialing and payer enrollment activities, ensuring compliance with regulatory standards and payer requirements. This senior-level role mentors' junior staff, supports the onboarding and training of new team members, and provides subject matter expertise in managed care credentialing. The Senior Specialist also plays a pivotal role in special initiatives, including technology implementations and establishing new payer delegation arrangements, while maintaining a high level of accuracy, timeliness, and collaboration across departments.

PATIENT AGE GROUP(S) AND POPULATION(S) SERVED
Refer to departmental "Scope of Service" and "Provision of Care" plans, as applicable, for description of primary age groups and populations served by this job for the respective HM entity.

HOUSTON METHODIST EXPERIENCE EXPECTATIONS

• Provide personalized care and service by consistently demonstrating our I CARE values:
  • INTEGRITY: We are honest and ethical in all we say and do.
  • COMPASSION: We embrace the whole person including emotional, ethical, physical, and spiritual needs.
  • ACCOUNTABILITY: We hold ourselves accountable for all our actions.
  • RESPECT: We treat every individual as a person of worth, dignity, and value.
  • EXCELLENCE: We strive to be the best at what we do and a model for others to emulate.

• Practices the Caring and Serving Model

• Delivers personalized service using HM Service Standards

• Provides for exceptional patient/customer experiences by following our Standards of Practice of always using Positive Language (AIDET, Managing Up, Key Words)

• Intentionally collaborates with other healthcare professionals involved in patients/customers or employees' experiential journeys to ensure strong communication, ease of access to information, and a seamless experience

• Involves patients (customers) in shift/handoff reports by enabling their participation in their plan of care as applicable to the given job

• Actively supports the organization's vision, fulfills the mission and abides by the I CARE values

PEOPLE ESSENTIAL FUNCTIONS

• Serves as a mentor and resource to junior credentialing staff, providing guidance, support, and training.

• Facilitates onboarding and continuous education for newly hired credentialing team members.

• Effectively communicates with providers, internal stakeholders, and payers to resolve escalated credentialing issues.

• Builds collaborative relationships with departments to ensure alignment of credentialing timelines and organizational priorities. Conducts self in a manner that is congruent with cultural diversity, equity, and inclusion principles. Contributes toward improvement of department scores for employee engagement, including peer-to-peer accountability.

SERVICE ESSENTIAL FUNCTIONS

• Leads the credentialing and payer enrollment process for new providers, ensuring accurate, complete, and timely submission of all documentation.

• Oversees delegation of credentialing responsibilities for assigned projects or payers, ensuring timelines and expectations are met.

• Partners with internal departments on cross-functional initiatives to improve the provider onboarding and credentialing experience.

QUALITY/SAFETY ESSENTIAL FUNCTIONS

• Performs in-depth audits of provider files to ensure compliance with regulatory, payer, and organizational requirements.

• Identifies and investigates credentialing discrepancies, taking corrective actions and escalating as appropriate.

• Ensures quality standards are consistently met and leads process improvement efforts in credentialing workflows.

FINANCE ESSENTIAL FUNCTIONS

• Collaborates with Managed Care and Revenue Cycle departments to resolve payer-related delays that impact revenue cycle performance. Utilizes resources with cost-effectiveness and value creation in mind. Self-motivated to manage time effectively and prioritize tasks independently, while supporting coworkers as needed.

• Ensures documentation is submitted to payers promptly to avoid delays in reimbursement and support timely patient care delivery.

GROWTH/INNOVATION ESSENTIAL FUNCTIONS

• Leads or participates in the implementation of new credentialing technology or process improvements.

• Assists in launching new payer delegation arrangements and managing credentialing requirements for new contracts.

• Proactively identifies opportunities for self and team development, takes appropriate action, and ensures career discussions occur with management. Completes and updates the My Development Plan on an ongoing basis.

This job description is not intended to be all-inclusive; the employee will also perform other reasonably related business/job duties as assigned. Houston Methodist reserves the right to revise job duties and responsibilities as the need arises.

EDUCATION

• High School diploma or equivalent education (examples include: GED, verification of homeschool equivalency, partial or full completion of post-secondary education, etc.)

WORK EXPERIENCE

• 5 years of experience in physician credentialing, provider enrollment, or a related healthcare administrative role

• Experience with delegated credentialing arrangements and credentialing software systems strongly preferred

LICENSES AND CERTIFICATIONS - REQUIRED

• N/A

LICENSES AND CERTIFICATIONS - PREFERRED

• CPMSM - Certified Professional Medical Services Management (NAMSS) OR
• CPCS - Certified Provider Credentialing Specialist (NAMSS)

KNOWLEDGE, SKILLS, AND ABILITIES

• Demonstrates the skills and competencies necessary to safely perform the assigned job, determined through ongoing skills, competency assessments, and performance evaluations

• Sufficient proficiency in speaking, reading, and writing the English language necessary to perform the essential functions of this job, especially with regard to activities impacting patient or employee safety or security

• Strong interpersonal and communication skills to engage effectively with internal stakeholders, health plans, and providers, using a service-oriented and solutions-focused approach

• Proven ability to lead, mentor, and train junior staff, fostering professional development and team collaboration

• Excellent organizational and time management skills, with the ability to independently manage multiple priorities and high-volume credentialing activities

• Demonstrates strong attention to detail and a commitment to accuracy, ensuring high-quality documentation and data integrity

• Proficient in the use of credentialing software systems and intermediate to advanced skills in Microsoft Office Suite (Word, Excel, Outlook, Teams)

• Ability to analyze and interpret regulatory, payer, and organizational requirements and apply them effectively to credentialing processes

• Skilled in identifying process improvement opportunities and participating in implementation of new tools, workflows, or systems

• Demonstrates initiative and accountability in completing tasks and contributing to departmental goals, while maintaining a commitment to continuous learning and growth

SUPPLEMENTAL REQUIREMENTS

WORK ATTIRE

• Uniform No
• Scrubs No
• Business professional Yes
• Other (department approved) No

ON-CALL*
*Note that employees may be required to be on-call during emergencies (ie. DIsaster, Severe Weather Events, etc) regardless of selection below.

• On Call* No

TRAVEL**
**Travel specifications may vary by department**

• May require travel within the Houston Metropolitan area No
• May require travel outside Houston Metropolitan area No

Houston Methodist Specialty Physician Group - As one of the nation’s leading hospitals and academic medical centers Houston Methodist has brought together some of the nation’s leading experts in multiple specialties to serve our patients.  As part of Houston Methodist Specialty Physician Group (HMSPG), these specialists not only provide excellent clinical care, but are on the forefront of research, developing leading-edge technologies and treatments, and teaching the medical pioneers of tomorrow.  This combination of clinical service, research and academics ensures patients have access to the latest in treatments and technologies while providing the best in comprehensive patient care.  Established as a non-profit corporation and certified by the Texas State Board of Medical Examiners, HMSPG enables physicians to maintain autonomy with respect to their clinical practice while growing their practice within an academic environment.