Scheduled Hours

40

Position Summary

Provides operational leadership for WashU Medicine's delegated credentialing organization, special contracting and negotiation of managed care contract language. Works jointly with the Senior Director of Managed Care Financial Contracting and Rate Analysis to secure optimal terms of participation with third-party managed care organizations.

Job Description

• Manages WashU Medicine's delegated credentialing organization.
• Manages WashU Physician’s Network (WUPN). 
• Develops and implements policies and procedures pertaining to collection, and scope, of information required to carry out credentialing and re-credentialing functions.
• Designs and manages a centralized practitioner database and the mechanism for direct or indirect access by staff and representatives of affiliated organizations. Assures an accurate, complete, and well-documented information source.
• Maintains up-to-date knowledge of, and compliance with, credentialing standards established by the National Committee for Quality Assurance (NCQA), Joint Commission on the Accreditation of Healthcare Organization (JCAHO), Utilization Review Accreditation Commission (URAC), any state or federal medical staff credentialing requirements and the delegation agreement of any applicable care plans.
• Advises administrative staff of affiliated physician organizations, hospitals, managed care plans and other third parties on issues pertaining to credentialing and re-credentialing.
• Establishes and assures adherence to credentialing data confidentiality policy.
• Designs and conducts training and educational programs as required to assure credentialing compliance standards with hospital programs, delegated credentialing corporate representative, credentialing bodies and the internal committees.
• Develops infrastructure to assure the accuracy and consistency of the interface with the National Practitioner Data Bank (NPDB), Federation of State Medical Boards (FSMB) Medicare, Medicaid, medical schools, societies, and the Departments of Insurance or Health. Serves as authorized agent in reporting of adverse actions to any such organization.
• Designs and executes the pre-application, application and reapplication process associated with credentialing and re-credentialing. Provides direct oversight of site visit nurse responsible for assessment of physician’s office environment and medical records.
• Coordinates site audits by managed care plans, accrediting bodies and state or federal agencies.
• Leads medical school liaison for transplant contracting.
• Maintains operational oversite of WashU Medicine's single patient discount contracting service.
• Responsible for negotiation of managed care contract language and securing acceptable managed care language terms.
• Works jointly with the Senior Director of Managed Care Financial Contracting and Rate Analysis to secure optimal financial terms for all third-party agreements.
• Along with the Senior Director of Special Contracting and Contract Language, serves as the primary faculty practice plan liaison with BJC managed care contracting.
• Performs other duties as assigned.

Working Conditions:
Job Location/Working Conditions

• Normal office environment 

Physical Effort

• Typically sitting at a desk or table 

Equipment

• Office equipment 

The above statements are intended to describe the general nature and level of work performed by people assigned to this classification. They are not intended to be construed as an exhaustive list of all job duties performed by the personnel so classified. Management reserves the right to revise or amend duties at any time.

Required Qualifications

Education:

Bachelor's degree

Certifications/Professional Licenses:

No specific certification/professional license is required for this position.

Work Experience:

No specific work experience is required for this position.

Skills:

Not Applicable

Driver's License:

A driver's license is not required for this position.

More About This Job

WashU seeks highly motivated individuals who are able to perform duties in a manner consistent with our core mission and guiding principles.

Preferred Qualifications

Education:

Master's degree, Ph.D. - Doctor of Philosophy

Certific