PRINCIPAL RESPONSIBILITIES: The Credentialing Coordinator works under the supervision of the Manager, 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 (i.e., Title 22, NCQA, DHCS, DMHC, and CMS).
Principal responsibilities include:
Application Maintenance
Prepare initial application requests for Chief Medical Officer or Medical Director review. Send and track application requests. Evaluate 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 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 Manager, Peer Review and Credentialing of potential issues. Peer Review and Credentialing Committee Maintenance
Provide administrative support for Peer Review and Credentialing Committee (PRCC) meetings. Prepare and send email reminders to members to ensure a quorum. Prepare agendas, files and needed materials. Assemble meeting packets and/or web-based meetings. Plan and schedule meeting space and order catering for meetings. Take minutes, complete follow up correspondence, and update the credentialing database. Credentialing Requirements Maintenance
Monitor on-going state, federal, and licensing 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 Manager of Peer Review & Credentialing with delegated or internal credentialing audits, HEDIS, and other projects as assigned. Assist Manager of Peer Review & Credentialing in providing credentialing information to other Alliance departments and staff (Contracting, Medical Services, Provider Services, Senior Staff, Medical Director, and Chief Medical Officer, etc.) as required. Complete other duties and special projects as assigned. ESSENTIAL FUNCTIONS OF THE JOB Researching: Must be able to access a variety of sources including computer-related sources and paper files in order to review information in files/computer 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, vendors, and health plan members. Prepare and deliver oral presentations to committee members. Prepare Peer Review and Credentialing 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 preferred. 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. SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): Working knowledge of Medical Staff principles and operations specific to regulatory expectations. Sound knowledge and understanding of Credentialing Committee and peer review process. Experience with 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 $26.07 - $39.10 HOURLY The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit. We strive to have the best qualified person in every job. Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws. M/F/Vets/Disabled.