Managed Care Analyst I

Where compassion meets innovation and technology and our employees are family.

GENERAL PURPOSE OF JOB:
Responsible for all aspects of the credentialing, re-credentialing, enrollment process for hospital and hospital employed providers with contracted health plans. Maintains up to date data for each provider in credentialing databases and online systems; ensures timely renewal of license, and certifications.  Understands the insurance plan requirements for credentialing types of providers.  Through research and analysis, the Managed Care Analyst I will assist with establishing and maintaining administrative, legal, operational, and financial opportunities related to contract negotiation and implementation for all areas of managed care.

ESSENTIAL DUTIES AND RESPONSIBILITIES:
To perform this job successfully, an individual must be able to each essential duty satisfactorily.  The requirements listed below are representative the knowledge, skill, and/or ability required.  Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. This job description is not intended to be all-inclusive; employees will perform other reasonably related business duties as assigned by the immediate supervisor and/or hospital administration as required.
• Maintain utmost level of confidentiality at all times.
• Adhere to hospital policies and procedures.
• Demonstrate business practices and personal actions that are ethical and adhere to corporate compliance and integrity guidelines. 
• Compiles and maintains current and accurate data for hospital and hospital employed providers.
• Maintains copies of current state license, CLIA certificates, education requirements and any other required credentialing documents for hospital and hospital employed providers.
• Ability to communicate effectively with all stakeholders across the health system, furthermore, disseminate manage care credentialing updates to key senior leaders across the health system.
• Maintains knowledge of current health plan and hospital requirements for credentialing providers.

• Sets up and maintains provider information in online (internally and external insurance companies) payer credentialing databases and systems.
• Tracks licenses and certification expirations for all providers to ensure timely renewals.
• Establishes and maintains provider files to include necessary documentation and understands the plan requirements for credentialing a provider with all of insurance carriers we currently participate with for all types of providers.
• Assist departmental leadership in resolving managed care operational issues and provide interpretation of managed care policies, terms, and conditions.
• Knowledge of Medicare and Medicaid provider enrollment rules and guidelines.
• Complete enrollment applications for various state Medicaid plans
• Initiate and support the facility credentialing application process by sending, receiving, analyzing facility documents to determine appropriateness for the facility verification process
• Gather, verify, and evaluate confidential and sensitive organizational information, consistent with facility credentialing application requirements
• Follows up on the status of applications and provider licenses and facilitates the renewal process; tracks the progress on all pending applications and works to resolve issues as they arise.
• Oversees provider online database, tracks licensure expirations and ensures that updated licensures are received.
• Manage documentation and proper communication workflows for all new provider credentialing
• Supports special project work as needed.
• Assumes additional duties as required

EDUCATION AND/OR EXPERIENCE:

• Bachelor's degree in Business Administration or Health Care Administration preferred; other related degrees will be considered based on applicability.
• 3-5 years' previous credentialing/enrollment or provider relations experience in related area
• Substantial knowledge of payer credentialing
• Knowledge of payer processes, local, state, and federal requirements
• High level of skills in operating a standard desktop and Windows-based computer system, including but not limited to, Microsoft Word, Excel, PowerPoint, Outlook, database applications, presentation software, Intranet and computer navigation
• Excellent organizational, analytical, time management and attention-to-detail skills for the execution of multiple assignments.
• Ability to work collaboratively in a team-oriented environment; courteous, professional and friendly demeanor
• Ability to work independently with minimal supervision, plan, organize, prioritize assignments and responsibilities and time constraints in a fast-paced environment and adapt to them as they change frequently
• Prior experience with EPIC is a plus
• Strong oral and written communication skills
• Strong organizational skills
• Ability to cross-train in other areas of the department in order to achieve smooth flow of all operations
• Ability to multi-task and work on multiple projects simultaneously