Director of Managed Care Contracting & Provider Credentialing SMS-3835

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Description

Under the direct supervision of the Executive Director of Clinical Finance with a dotted line to the Executive Director of Revenue Cycle for Provider Credentialing; the Director of Managed Care Contracting & Provider Credentialing is responsible for providing strategic leadership financial and administrative oversight of Managed Care contracting with commercial and governmental payers on behalf of SIU Medicine (SIU P&S and SIU FQHC) working closely with departmental staff and physician leadership to develop a portfolio of participating network contracts to enhance revenue and patient access. The Director will also be responsible for oversight and the providing of strategic leadership to the Credentialing Department and will assist with developing credentialing policies and procedures when needed. Responsible for providing on-going analysis of SIU Medicines risk-based insurance products held in joint venture with partner organizations. Works closely with the Executive Director of Clinical Finance and Managed Care Analyst on reimbursement modeling and the revenue cycle team for payer variance analysis and payer issues.

Examples of Duties

Administration: Managed Care 60%
in conjunction with the Manage Care Advisory Group and execute the organizations managed care strategy aligned with financial and operation goals.
strategic recommendations to executive leadership regarding payer strategy and contractil)g priorities.
coordinates the development negotiation implementation monitoring and management of all SIU Medicine managed care agreements including delegated credentialing.
contract renewals amendments and terminations and maintain a comprehensive contract management system.
new managed care contracts and coordinates with key staff to communicate the contract guidelines.
payer relationships with a focus on promoting proactive professional and collaborative relationships problem resolution and avoidance of future issues whenever possible.
as the primary organizational contact for manage care issues.
and monitor financial aspects of existing managed care contracts. Utilize analysis for feedback on contract renewals renegotiations or terminations. Make
recommendations regarding participation or non-participation with new or existing agreements.
as the managed care subject matter expert.
effective communication with departmental leadership and staff. This includes engaging employees by sharing business information solving problems and identifying solutions as a team. Promotes direct honest open and timely communication throughout the practice.
closely with the Executive Director of Clinical Finance and Financial Analyst on revenue modeling and contracting issues.
monthly financial updates to leadership as it relates to SIUs risk-based insurance products held in joint venture with partner organizations providing ongoing claims analysis as it relates to plan performance.
other job duties as assigned.

Administration: Provider Credentialing 40%
strategic leadership and oversight of the organizations credentialing and privileging function across a multispecialty provider network.
supervise and develop the credentialing team establishing performance expectations workflows productivity standards and accountability measures.
initial and ongoing credentialing and recredentialing of physicians advanced practice providers and other credentialed practitioners with commercial and government payers.
hospital and facility privileging activities including initial appointments reappointments privilege renewals and maintenance of provider affiliations.
timely enrollment credentialing and recredentialing with Medicare Medicaid commercial health plans managed care organizations and other applicable payers.
oversight of the credentialing management system including rosters ensuring provider records documentation status information and reporting are complete accurate and current.
and maintain standardized credentialing policies procedures workflows and internal controls to promote accuracy efficiency consistency and regulatory compliance.
credentialing and privileging timelines outstanding applications expiring credentials and other key performance indicators to prevent lapses that could affect provider participation privileges billing or revenue.
the Credentialing Committee providing subject matter expertise and guidance regarding background findings and issues identified during provider file reviews.
excellent customer service and adhere to SIUs Code of Conduct and Ethics Standards.
other job duties as assigned.

Qualifications

Minimum Qualifications:
1. Bachelors Degree in Healthcare Administration Business Administration or related field required.
2. Extensive knowledge and experience with health insurance claim data and/or Managed Care payment
methodologies.
3. Knowledge of Federal and State regulatory environment related to Managed Care. Minimum 7-10 years
of experience working with and negotiating Managed Care contracts with payers and/or negotiating
contracts on behalf of a managed care organization.
4. Sensitive to the needs of underrepresented minority populations.

Desired Qualifications:
1. Masters Degree highly desired.
2. Previous management experience desired.

Supplemental Information

If you require assistance please contact the Office of Human Resources at or call Monday through Friday 8:00am-4:30pm.

The mission of Southern Illinois University School of Medicine is to optimize the health of the people of central and southern Illinois through education patient care research and service to the community.

The SIU School of Medicine Annual Security Report is available online at report contains policy statements and crime statistics for Southern Illinois University School of Medicine in Springfield IL. This report is published in compliance with Federal Law titled the
Jeanne Clery Disclosure of Campus Security Policy and Crime Statistics Act.

Southern Illinois University School of Medicine is an Affirmative Action/Equal Opportunity employer who provides equal employment and educational opportunities for all qualified persons without regard to race color religion sex national origin age disabilitysexual orientationprotected veteran status or marital status in accordance with local state and federal law.

Pre-employment background screenings required.

Required Experience:

Director