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Position Classification Description

Position Class Code / Title: A6016 / Tricare Credentialing Manager
Recruitment Tier: Tier 1
FLSA: Exempt
Grade: 13

This is a description of a Staff Position Classification. It is not an announcement of a position opening. To view descriptions of current openings, please go to UNMJobs and Search Postings to view positions that are currently accepting applications.

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 so classified.

Summary

Administers the credentialing process for all Tricare patient care providers, in accordance with JCAHO, Tricare, and URAC accreditation standards, Federal and State laws, and provisions of the New Mexico Department of Insurance. Coordinates the administration of credentialing policies and procedures, bylaws, rules and regulations, and patient/provider complaints for the Tricare Network. Serves as a primary point of liaison between the Health Sciences Center, Tricare management, and the Triwest Healthcare Alliance on provider credentialing and related issues.

Duties and Responsibilities

  1. Coordinates, oversees, and administers the credentialing and privileging process for all Tricare Network patient care providers, in accordance with JCAHO, Tricare, and URAC accreditation standards, Federal and State laws, and provisions of the New Mexico Department of Insurance, and University policies.
  2. Monitors the currency and accuracy of Tricare Network rules, regulations, and policies and procedures, ensuring compliance with accrediting organization requirements; reviews policies and develops, recommends, and/or implements changes, revisions, and enhancements as appropriate to current operating conditions.
  3. Reviews, oversees, and advises potential and/or existing network providers regarding credentialing appointments and reappointments; advises on all related documentation requirements for network participation.
  4. Provides on-site consultations to Tricare Network providers with regards to credentialing practices and services; prepares and conducts credentialing orientations and provides updates as appropriate on new policies and procedures.
  5. Prepares and submits recommendations regarding appointments and reappointments to the HSC Tricare credentialing committee, based on verifications and assessments.
  6. Analyzes JCAHO, Tricare, and URAC standards and develops criteria to ensure compliance; revises general aspects of the credentialing process as necessary; makes recommendations for and implements changes in process manuals; prepares, coordinates, and conducts delegated external credentialing audits.
  7. Functions as primary contact for all internal and external inquiries regarding Tricare Network credentialing; serves as a primary point of credentialing liaison between HSC Tricare management, Triwest, other Tricare Network subcontractors, and the Department of Defense; develops and maintains positive working relationships.
  8. Manages the HSC's Tricare program credentialing and provider network database; monitors critical data for extensive analysis and report generation.
  9. Supervises personnel which typically includes recommendations for hiring, firing, performance evaluation, training, work allocation, and problem resolution.
  10. Oversees and monitors performance, work quality, and contract adherence of the designated credentials verification contractor and the provider database contractor.
  11. Oversees and coordinates the tracking of various physician testing and performance data for Tricare and Triwest, as required by federal and state laws and regulations, or in accordance with Tricare requirements and policies.
  12. Participates in the development and management of annual operating budgets for the unit, as appropriate.
  13. Represents the office to internal and external customers as appropriate; makes presentations to and interacts with various internal and external customers, HSC groups, other academic institutions, and external conferences on issues pertinent to area of specialty.
  14. Performs miscellaneous job-related duties as assigned.

Minimum Job Requirements

  • Bachelor's degree; at least 3 years of experience directly related to the duties and responsibilities specified.
  • Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.

Knowledge, Skills and Abilities Required

  • Ability to develop and deliver presentations.
  • Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.
  • Ability to process computer data and to format and generate reports.
  • Knowledge of related accreditation and certification requirements.
  • Database management skills.
  • Knowledge of budget preparation
  • Ability to make administrative/procedural decisions and judgments.
  • Ability to coordinate and/or supervise independent contractors.
  • Ability to investigate and analyze information and draw conclusions.
  • Ability to supervise and train employees, to include organizing, prioritizing, and scheduling work assignments.
  • Knowledge of medical staff policies, regulations, and bylaws and the legal environment within which they operate.
  • Skill in developing policy and procedure documentation.
  • Ability to foster a cooperative work environment.
  • Knowledge of medical credentialing policies, procedures, and standards.
  • Knowledge of web page development and website maintenance.

Working Conditions and Physical Effort

  • No or very limited exposure to physical risk.
  • Work is normally performed in a typical interior/office work environment.
  • Light physical effort; requires handling of average-weight objects up to 10 lbs or some standing and/or walking.

The University of New Mexico provides all training required by OSHA to ensure employee safety.

Revised Date: 03/20/2017