Hybrid: Applicants must be a California resident as of their first day of employment.
The Credentialing Coordinator works under the supervision of the Supervisor, Peer Review and Credentialing and assists in all aspects of the Credentialing department functions. The Credentialing Coordinator is responsible for coordinating, monitoring, and maintaining the credentialing and recredentialing processes of health care providers and practitioners to ensure they meet the requirements of the Alliance credentialing policies and regulatory agencies including, but not limited to, Title 22, National Committee for Quality Assurance (NCQA), the Department of Health Care Services (DHCS), the Department of Managed Health Care (DMHC), and the Centers for Medicare and Medicaid Services (CMS).
Principal responsibilities include:
Application Maintenance
- Prepare initial Credentialing application requests for Chief Medical Officer or Medical Director review.
- Send and track Credentialing application requests.
- Evaluate Credentialing applications for completeness and compliance.
- Coordinate initial and recredentialing file processing with Credentialing Verification Organization (CVO).
- Audit files, obtain credentialing documents or additional information as required.
- Track and follow up on all credentialing/recredentialing documentation as necessary.
- Contact practitioners to clarify discrepancies.
- Ensure Credentialing application timeliness per NCQA requirements.
Credentialing Database Maintenance
- Perform data entry and maintain accuracy and integrity of the credentialing database system.
- Produce credentialing reports as required for Alliance departments, CVO, and special requests.
- Review expirable reports and notify Supervisor, Peer Review and Credentialing of potential issues.
Peer Review and Credentialing Committee Maintenance
- Provide administrative support for Peer Review Committee (PRC) and the Credentialing Committee (CC) meetings.
- Prepare and send email reminders to committee members to ensure a quorum.
- Prepare agendas, files, and needed materials.
- Assemble meeting packets for meetings.
- Take minutes, complete follow up correspondence, and update the credentialing database.
Credentialing Requirements Maintenance
- Monitor on-going state, federal, and licensing agencies to identify potential provider sanctions on a monthly basis.
- Ensure credentialing compliance standards are met per accrediting and regulatory agencies (i.e., Title 22, NCQA, DHCS, DMHC, CMS) while developing and maintaining a working knowledge of statues and laws.
- Assist Supervisor, Peer Review & Credentialing with delegated or internal credentialing audits, HEDIS, and other projects as assigned.
- Assist Supervisor, Peer Review & Credentialing in providing credentialing information to other Alliance departments and staff (Contracting, Health Care Services, Provider Services, Senior Staff, Medical Director, and/or Chief Medical Officer, etc.) as required.
- Complete other duties and special projects as assigned.
ESSENTIAL FUNCTIONS OF THE JOB
- Perform research by accessing a variety of sources including computer-related sources and paper files in order to review information and report details back to a provider or Alliance staff as appropriate.
- Communicate effectively and efficiently internally and externally and serve as a liaison between providers and vendors. Prepare Peer Review Committee and Credentialing Committee meeting minutes, agendas, medical record summaries, and provider audit performance summaries, monthly or as needed.
- Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
PHYSICAL REQUIREMENTS
- Constant and close visual work at desk or computer.
- Constant data entry using keyboard and/or mouse.
- Constant sitting and working at desk.
- Frequent use of telephone headset.
- Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
- Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
- Frequent walking and standing.
Number of Employees Supervised: 0
MINIMUM QUALIFICATIONS:
EDUCATION OR TRAINING EQUIVALENT TO:
- Bachelor’s degree or equivalent experience.
- NAMSS Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Staff Management (CPMSM) certification preferred.
MINIMUM YEARS OF ADDITIONAL RELATED EXPERIENCE:
- One to three years experience within a health care/managed care environment required.
- Knowledge of commonly used concepts, practices, and procedures used in health care credentialing.
- Minimum two years previous credentialing experience preferred.
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SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE):
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Working knowledge of Medical Staff principles and operations specific to regulatory expectations.
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Sound knowledge and understanding of Credentialing Committee and Peer Review Committee processes.
- Experience with Symplr (formerly CACTUS) Software or similar credentialing system.
- Possess excellent interpersonal, writing, and communication skills.
- Possess excellent organizational skills and attention to detail.
- Able to maintain strict adherence to deadlines.
- Able to meet productivity and quality goals.
- Able to build successful internal and external customer relations.
- Able to function well within a team environment and independently.
- Able to maintain confidentiality.
- Possess intermediate Microsoft Office skills in Microsoft Word, Excel, Outlook, and PowerPoint.
SALARY RANGE $27.11 - $40.66 HOURLY
The Alliance is an equal opportunity employer and makes all employment decisions on the basis of merit and business necessity. We strive to have the best-qualified person in every job. The Alliance prohibits unlawful discrimination against any employee or applicant for employment based on race, color, religious creed, sex, gender, transgender status, age, sexual orientation, national origin, ethnicity, citizenship, ancestry, religion, marital status, familial status, status as a victim of domestic violence, assault or stalking, military service/veteran status, physical or mental disability, genetic information, medical condition, employees requesting accommodation of a disability or religious belief, political affiliation or activities, or any other status protected by federal, state, or local laws.
