Credential and Managed Care Coordinator

SCOPE:

Under direct supervision, maintains and coordinates actions for provider credentialing, licensure, and hospital privileges activities. Provides administrative support to state/practice managed care functions, which may include provider plan participation and credentialing, contract, files, explanation of benefits (EOB) analysis and managed care reporting. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Credentials and re-credentials providers according to quality standards and company policies and procedures. Notifies providers of licensure expirations and submits licensure applications and renewal forms with payment to State agencies and appropriate departments.

Updates and maintains current provider licensure files and provides information to hospitals and other healthcare providers as appropriate. Requests and completes hospital credentialing and privileges applications for providers.

Obtains and maintains provider participation in managed care plans in a timely manner and communicates information to practice sites and business office.

Sets-up and maintains the contract management system to include terms of the contract, providers credentialed to the payor and other contracted service providers (labs, hospitals).

Maintains contract filing systems.

May complete EOB analyses or fee schedule variance reporting on a monthly basis for the top Managed Care payors according to policy and procedure. May produce monthly managed care reports and implements new analysis tools to assist in reporting functions.

May maintain expected reimbursement by CPT code for the top payor contracts in each market and communicate changes to system librarian.

Supports Network Contracting Representative/Manager in general administrative functions.

Other duties as requested or assigned.

MINIMUM QUALIFICATIONS:

High school diploma or equivalent required. Some physician credentialing and/or managed care support experience preferred.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is required to be present at the employee site during regularly scheduled business hours and regularly required to sit or stand and talk or hear. Requires full range of body motion including handling and lifting patients, manual and finger dexterity, and eye-hand coordination. Requires standing and walking for extensive periods of time. Occasionally lifts and carries items weighing up to 40 lbs. Requires corrected vision and hearing to normal range.

COMPETENCIES:

Uses Technical and Functional Experience: Possesses up to date knowledge of the profession and industry; is regarded as an expert in the technical/functional area; accesses and uses other expert resources when appropriate.

Demonstrates Adaptability: Handles Day to day work challenges confidently; is willing and able to adjust to multiple demands, shifting priorities, ambiguity, and rapid change; shows resilience in the face of constraints, frustrations, or adversity; demonstrates flexibility.

Uses Sound Judgment: Makes timely, cost effective and sound decisions; makes decisions under conditions of uncertainty.

Shows Work Commitment: Sets high standards of performance; pursues aggressive goals and works efficiently to achieve them. Commits to Quality: Emphasizes the need to deliver quality products and/or services; defines standards for quality and evaluated products, Job Profile Summary processes, and service against those standards; manages quality; improves efficiencies.

WORK ENVIRONMENT:

The work environment may include exposure to communicable diseases, toxic substances, ionizing radiation, medical preparations, and other conditions common to an oncology/hematology clinic environment. Work will involve in-person interaction with co-workers and management and/or clients. Work may require minimal travel by automobile to office sites.