Job Summary

Oversees the operations of Western Kentucky Healthcare System (WKHS). Develops, manages, and monitors the managed care contracting, credentialing, and provider enrollment processes. Works under the supervision of the Managed Care Director.

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.

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

• One to two years of experience with one year directly related to managed care credentialing is preferred.

• Proficiency in Microsoft Word and Excel.