Managed Care Specialist

Job Summary

Handles credentialing and enrollment processes for healthcare providers and facilities. This role is critical to the operations of Western Kentucky Healthcare System (WKHS) and the Jennie Stuart Health Managed Care Department, supporting accurate provider setup and alignment with payer requirements. In addition, the Specialist partners with clinical, operational, and financial departments to provide education, training, and guidance on revenue integrity practices—including accurate charge capture and documentation standards—to strengthen compliant billing and optimize reimbursement.

Job Requirements

Minimum Education

·         Bachelor’s degree in Healthcare Administration, Business, or a related field preferred.

·         Minimum of 5 years of experience in hospital revenue cycle.

Essential Functions

·         Manages payer credentialing and enrollment follow-up processes.

·         Completes and ensures the accuracy of credentialing and enrollment tasks.

·         Reviews incoming correspondence, takes action to resolve issues, and escalates complex matters to relevant departments as needed to ensure resolution.

·         Resolves credentialing and enrollment issues as liaison between provider and payer.

·         Monitors credentialing applications and documentation with a high level of accountability, tracking expiration dates and ensuring timely and accurate updates.

·         Ensures the ongoing accuracy of provider databases.

·         Meets full compliance with required timelines.

·         Collaborates with clinical and operational leaders to identify gaps or errors in current workflows and provides education to prevent issues.

·         Serves as an ongoing resource to support continuous improvement in reimbursement accuracy.

·         Other duties as assigned, contributing expertise in other areas as needed.

Organizational Expectations

• Demonstrates decision-making capabilities.
• Possesses analytical skills.
• Exhibits exceptional verbal and written communication skills.
• Demonstrates expertise in cultivating a collaborative, results-driven work environment, fostering a culture of continuous improvement and innovation.
• Proficiency in database management.
• Strong interpersonal and communication skills.
• Skill in Microsoft Word and Excel.
• Comprehensive understanding of payer policies, regulations, and the legal frameworks governing healthcare credentialing and enrollment processes.

Organizational Expectations

• Demonstrates decision-making capabilities.
• Possesses analytical skills.
• Exhibits exceptional verbal and written communication skills.
• Demonstrates expertise in cultivating a collaborative, results-driven work environment, fostering a culture of continuous improvement and innovation.
• Proficiency in database management.
• Strong interpersonal and communication skills.
• Skill in Microsoft Word and Excel.
• Comprehensive understanding of payer policies, regulations, and the legal frameworks governing healthcare credentialing and enrollment processes.

Minimum Education

·         Bachelor’s degree in Healthcare Administration, Business, or a related field preferred.

·         Minimum of 5 years of experience in hospital revenue cycle.