Managed Care Delegation Specialist

It's more than a career, it's a calling.

WI-St. Agnes Hospital

Worker Type:

Regular

Job Summary:

Responsible for provider enrollment with commercial payors, managed care contracts, and delegation audit activities for the system hospitals or organization. Works independently with complex data and situations.

Job Responsibilities and Requirements:

PRIMARY RESPONSIBILITIES

• Ensures providers are credentialed and enrolled in insurance plans.

• Acts as a liaison between medical staff offices, credentialing verification offices, and delegation payors.

• Remains knowledgeable of medical staff bylaws, rules and regulations, and policies for the system hospitals or organization. Stays up to date with National Committee for Quality Assurance (NCQA) standards and reports back to stakeholders with new information pertinent to credentialing.

• Manages delegated credentialing processes and assists in contracting with managed care plans. Reviews and interprets new and existing contracts to ensure they meet Managed Care Organization (MCO) specifications. Negotiates recommended changes to contracts to ensure compliance.

• Ensures monthly and quarterly notifications for provider updates are distributed. Provided notifications of on-going rosters, new providers, resignations and/or change of status requests, location changes, and/or changes in provider privileges.

• Utilizes a variety of databases and query tools to gather data. Ensures all requirements are well-defined from the MCO to meet reporting and analysis specifications.

• Works closely with team members to establish reporting and dashboards within applications that will support operations.

• Resolves reimbursement discrepancies with payors for credentialing issues.

• Performs other duties as assigned.

EDUCATION

• High School diploma/GED or 10 years of work experience

EXPERIENCE

• Three years' experience in medical office setting

PHYSICAL REQUIREMENTS

• Frequent lifting/carrying and pushing/pulling objects weighing 0-25 lbs.

• Frequent sitting, standing, walking, reaching and repetitive foot/leg and hand/arm movements.

• Frequent use of vision and depth perception for distances near (20 inches or less) and far (20 feet or more) and to identify and distinguish colors.

• Frequent use of hearing and speech to share information through oral communication. Ability to hear alarms, malfunctioning machinery, etc.

• Frequent keyboard use/data entry.

• Occasional bending, stooping, kneeling, squatting, twisting and gripping.

• Occasional lifting/carrying and pushing/pulling objects weighing 25-50 lbs.

• Rare climbing.

REQUIRED PROFESSIONAL LICENSE AND/OR CERTIFICATIONS

• None

Work Shift:

Day Shift (United States of America)

Job Type:

Employee

Department:

8411000038 MEDICAL STAFF OFFICE

Scheduled Weekly Hours:

40

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