Director, Manager Care Contracts and Credentialing Location:
UNMMG Office of Clinical Contract Services (OCCS)
Pay Range: DOE
Job Code: B7043
# of Openings: 1
Description Job Code/Title: B7043/ Director, Managed Care
Contracts and Credentialing
FLSA : Exempt
OPEN UNTIL FILLED
UNM Medical Group, Inc. (UNMMG) is the practice plan
organization for physicians and other medical providers associated
with the UNM Health Sciences Center. UNM Medical Group, Inc. is a
New Mexico non-profit corporation and is an equal opportunity
employer. UNMMG offers a competitive salary and an attractive
benefit package which includes medical, dental, vision, and life
insurance as well as tuition assistance, paid leave and 403b
retirement for benefits eligible employees.
The following statements are intended to describe, in broad
terms, the general functions and responsibility levels
characteristic of positions assigned to this classification. They
should not be viewed as an exhaustive list of the specific duties
and prerequisites applicable to individual positions that have been
Under limited supervision, oversees the management and
negotiations of a wide range of agreements with Managed Care
Organizations to include Commercial, Medicare and Medicaid
products. Develops and implements managed care contracting and
reimbursement policies for the organization. Ensures compliance
with the appropriate accrediting and regulatory agencies as
applicable. Supervises staff in the day-to-day management of the
contract implementation and credentialing and privileging process
and database management.
Duties and Responsibilities
Initiates and leads joint operation committees with designated
major contractors to facilitate contract implementation and
Identifies, analyzes, and evaluates contractual compliance
issues as they arise; resolves or facilitates resolution of
compliance-related problems among constituencies as
Responds to, initiates, and evaluates requests for managed care
contracts for multiple product lines and venues; makes
recommendations to leadership on appropriate course of action.
Reviews, negotiates, writes, and processes facility,
professional, ancillary and dental contracts for a wide variety of
managed care organizations.
Serves as an expert resource to internal and external
constituents with regards to managed care contract planning,
reimbursement, interpretation, implementation, and maintenance.
Directs the development of a managed care utilization,
reimbursement and contract database, producing and evaluating
contract performance reports, modeling facility and professional
(medical and dental) reimbursement rates, evaluating financial
contract modifications, and compiling and monitoring key managed
Directs all UNMHSC provider database functions and the
Medicare/Medicaid provider enrollment process.
Manages receipt of credentialing applications, performs review,
analysis and prepares files for review with recommendation to the
Manage the privileging process to include initial, re-privilege
and expansion requests, ensuring update and maintenance of
Manage the coordination and maintenance of the Ongoing
Professional Practice Evaluation (OPPE) and Focused Professional
Practice Evaluation (FPPE), re-appointment peer review process.
Assists in clinical privilege development, maintenance, and
periodic reviewed specialty specific clinical privilege criteria
Facilitate the Credentialing Workgroup process with oversight of
agenda and meeting packet preparation including supporting
documentation, minute taking, and credentials summary preparation,
information and follow-up on items for POC and Board of
Ensure continued compliance with regulatory and accreditation
agencies; AAAHC, CMS, NCQA, DOH, Federal and State laws and
standards as they relate to Credentialing and Privileging.
Performs miscellaneous job duties as assigned.
Bachelor's degree in related field with at least 7 years of
experience directly related to the duties and responsibilities
specified. A completed degree from an accredited institution above
the minimum qualifications may be substituted on a year for year
basis. Verification of education and licensure will be
required if selected for hire.
Knowledge, Skills and Abilities Required
Knowledge of computerized information systems used in financial
and/or accounting applications.
Organization skills, interpersonal skills, and the ability to
manage multiple projects simultaneously.
Ability to work effectively in a team environment.
Analytical and problem solving skills.
Ability to develop strategic and tactical plans, and prioritize
and organize projects to meet deadlines.
Ability to bring closure to contracts on time and within
designated parameters of profitability.
Advanced fluency in Microsoft Excel and PowerPoint; and database
tools such as Microsoft Access.
Ability to build and maintain strong business relationships with
internal and external clients.
Conditions of Employment
NAMSS Certification as a Certified Professional Medical Services
Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS)
or obtain certification within twelve months of hire.
Must be employment eligible as verified by the U.S. Dept. of
Health and Human Services Office of Inspector General (OIG) and the
Government Services Administration (GSA).
Must pass a pre-employment criminal background check.
Fingerprinting, and subsequent clearance, is required.
Must provide proof of varicella & MMR immunity or obtain
vaccinations within 90 days of employment.
If this position is assigned to a clinical area, successful
candidate will be required to complete a pre-placement medical
evaluation/health screen. Required N-95 mask fitting, testing,
vaccinations to include annual TST, Tdap, and Hepatitis B will be
determined based on location and nature of position.
Working Conditions and Physical Effort
Work is normally performed in a typical interior/office work
No or very limited exposure to physical risk.
No or very limited physical effort required.