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Credentialing and Compliance Manager in Anaheim at Prospect Medical Systems

Date Posted: 11/6/2018

Job Snapshot

Job Description

Credentialing and Compliance Manager

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

This position has the responsibilities to coordinate the development, maintenance and implementation of clinic credentialing and compliance programs.

Job Responsibilities/Duties

  • Review all provider credentialing and re-credentialing applications for completeness. Review and analyze credentialing documents, including education, residency and fellowship training, board certification and eligibility, licensure, professional work history, liability insurance, requests for clinical privileges and malpractice history.
  • Assess completeness of the information and provider's qualifications relative to established standards.
  • Determine appropriate verification and reference letters to be prepared for adequate processing of each individual application and reapplication.
  • Identify and flag adverse information from provider application materials for the purpose of conducting special follow up investigations.
  • Request facility site reviews from appropriate sources (i.e. Cal optima) on applicable providers.
  • Responsible for the generating, mailing, tracking, and subsequent processing of provider re- credentialing applications. All re- credentialing files are to be completed within 36 months' time frame.
  • Requires following credentialing policy and compliance schedule for sending up to 3 requests starting 6 months prior to credentialing expiration and making follow up calls according to policy.
  • Update new information as received via re-credentialing process. Maintain accuracy on the number of files submitted for the credentialing committee(s)
  • Review of health plan rosters/directory proof when presented within health plan deadline. This process includes verification of listed contract type, specialty, practice locations (address, phone and fax), panel status and hospital privileges. Submit necessary documentation to add missing providers and to remove termed providers that are still listed. Follow up with health plan after 90 days to confirm changes submitted via roster/ directory proof review were appropriately made.
  • Serve as point of contact on all compliance related items/tasks for the clinics, manage and ensure clinics follow all federal, state, and local laws and regulations.
  • Review and update compliance and HIPPA policies and procedures Plan, direct, and perform internal and compliance training/audits per the annual work plan and as requested by the Chief Compliance Officer and/or the Compliance Committee.


Minimum Education: Bachelor's Degree preferred.

Minimum Experience: Three to five (3-5) years of health care credentialing and compliance experiences.

Req. Certification/Licensure: None.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

  • Company 401K
  • Medical, dental, vision insurance
  • Paid time-off
  • Life insurance

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law:

Keywords : Compliance, Credentialing