Job Summary

Develops, manages, and monitors the managed care contracting, credentialing, and provider enrollment processes.

Organizational Expectations

• Ability to make administrative/procedural decisions and judgements.

• Ability to investigate and analyze information and draw conclusions.

• Ability to develop and deliver presentations.

• Ability to process computer data and to format and generate reports.

• Ability to supervise and train employees, to include organizing, prioritizing, and scheduling work assignments.

• Ability to communicate effectively, both orally and in writing.

• Ability to foster a cooperative work environment.

• Strong interpersonal and communication skills and the ability to work effectively with a wide range of constituencies in a diverse community.

• Skill in developing policy and procedure documentation.

• Database management skills.

• Employee development and performance management skills.

• Knowledge of related accreditation and certification requirements.

• Knowledge of credentialing procedures and standards.

• Knowledge of payer policies, regulations, and bylaws and the legal environment within which they operate.

• Knowledge of budget preparation.

Essential Functions

• Functions as primary managed care contracting, credentialing and enrollment contact for all internal and external inquiries. Manages managed care contract, credentialing, and enrollment projects.

• Manages the WKHS-specific bylaws, rules and regulations, and policies and procedures, ensuring compliance with accrediting organization requirements; participates in development and review of operating policies and procedures, Managed Care Delegated Credentialing policies and procedures; develops, recommends, and/or implements changes, revisions, and enhancements as appropriate to current operating environment.

• Coordinates and manages large, unresolved managed care issues. Serves as a liaison between provider and payor during resolution of credentialing and enrollment issues.

• Performs on-site evaluations across WKHS with regards to credentialing and regulatory requirements.

• Analyzes NCQA and CMS standards and develops criteria to ensure compliance; revises general aspects of credentialing process as necessary; makes recommendations for and implements changes in bylaws, policies, and procedures.

• Reviews correspondence received and performs appropriate action to resolve. Escalates items to other areas outside of department as needed.

• Represents Jennie Stuart Health to internal and external customers as appropriate; makes presentations to and interacts with various internal and external customers, community, and other institutions, and external conferences on issues pertinent to area of specialty.

• Performs miscellaneous job-related duties as assigned.

Required Skills

• A Bachelor of Science degree in business or healthcare-related field of study is preferred.

• A qualified candidate should have one to two years of experience with one year directly related to managed care credentialing.

• Proficiency in Microsoft Word and Excel.

Required Experience

• A Bachelor of Science degree in business or healthcare-related field of study is preferred.

• A qualified candidate should have one to two years of experience with one year directly related to managed care credentialing.

• Proficiency in Microsoft Word and Excel.