Managed Care Delegation Specialist

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

MO-SSM Health Mission Hill

Worker Type:

Regular

Job Highlights:

Remote role with initial onsite training and occasional in-person meetings required.

Schedule - M-F with start and stop times between 6am and 6pm. Candidate schedule during this timeframe must be consistent.

Preferred Skills. Experience with credentialing databases. Proficient in all Microsoft applications, advanced proficiency with Excel. Experience with provider relations and navigating issues. Strong communication skills both written and verbal are required.

The selected candidate will support all Regions.

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

Department:

8762010033 Managed Care Contract MO/IL

Work Shift:

Day Shift (United States of America)

Scheduled Weekly Hours:

40

Benefits:

SSM Health values our exceptional employees by offering a comprehensive benefits package to fit their needs.

• Paid Parental Leave: we offer eligible team members one week of paid parental leave for newborns or newly adopted children (pro-rated based on FTE). 

• Flexible Payment Options: our voluntary benefit offered through DailyPay offers eligible hourly team members instant access to their earned, unpaid base pay (fees may apply) before payday.

• Upfront Tuition Coverage: we provide upfront tuition coverage through FlexPath Funded for eligible team members. 

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SSM Health is an equal opportunity employer. SSM Health does not discriminate on the basis of race, color, religion, national origin, age, disability, sex, sexual orientation, gender identity, pregnancy, veteran status, or any other characteristic protected by applicable law. Click here to learn more.