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Credentialing Coordinator II in Orange at Prospect Medical Systems

Date Posted: 9/20/2018

Job Snapshot

  • Employee Type:
    Full-Time
  • Location:
    600 City Parkway West
    Orange
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
    9/20/2018
  • Job ID:
    10295

Job Description



Credentialing Coordinator II

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.

The Credentialing Coordinator II position performs credentialing and re-credentialing activities according to Prospect Medical Credentialing Policies, contracted health plan policies, CMS, DMHC, and NCQA accreditation guidelines. This position acts as a liaison between our IPAs and contracted health plans.



Job Responsibilities/Duties

  • Responsible for ensuring that Licensing Board Disciplinary Reports are ran and reviewed within a 30 day cycle as required.
  • Review monthly reports from Eligibility Department – Inactive PCP, Termed PCP and Unassigned.
  • Follow-up with health plans regarding providers identified on Eligibility reports. These reports include termed providers with assigned membership; specialists with assigned membership; and membership assigned to providers loaded into a non-contracted network.
  • Field questions from Internal Departments regarding PCP health plan listings.
  • Assignment of change forms and health plan rosters for review.
  • Review files processed by Credentialing Coordinator(s) prior to committee review.
  • HDO reviews and credentialing.
  • Semi-annual and quarterly reports.
  • 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 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 source (i.e. CalOptima) 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 month timeframe. Requires following Prospect Medical 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 80% accuracy rate on the number of files submitted for the credentialing committee(s).
  • Submit provider credentialing information to contracted health plans for inclusion in Prospect Medical networks (once required documentation is received from Contracting). Submissions include new provider adds, demographic changes, panel changes, age restrictions and terminations. 
  • Responsible for follow-up after submission to ensure that health plans appropriately processed the request and that provider information shows correctly on the health plan’s website.
  • Electronic Change Forms.
  • Process electronic change forms, except those relating to HDO.
  • The processing of electronic change forms includes updating CRDA, submitting information to health plans and/or internal departments.
  • For Primary Care Providers (Adds / Changes / Maintenance):
  • After submission for add / change / panel, confirm that health plans appropriately processed the submission and provider information shows correctly on the health plan’s website.
  • Maintain Provider ID Numbers in CRDA on Health Plan Tracking screen.
  • Required listing rate is 95%.
  • For Primary Care Providers (Terminations):
  • Responsible for notification to health plan and applicable Prospect Medical departments.
  • Notification includes date of contract termination, anticipated health plan termination (if different than contract termination) and provider for membership re-assignment (as indicated by Change Form.).
  • Membership reports are run via IDX every 30 days to track membership movement.
  • Follow-up with health plans that still show assigned membership after termination date (plus 30 days).
  • Review of health plan rosters / directory proof when presented within health plan deadline.
  • This process includes verification of listed contract type, specialty, practice location (address, phone, fax), panel status and hospital privileges.
  • Submit necessary documentation to add missing providers.
  • Submit necessary documentation 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.
  • Demonstrate and maintain credentialing knowledge. Keep abreast of new and changing regulations and standards.
  • Expirables, on-going monitoring.
  • Other duties as assigned by Management.


Qualifications

Minimum Education: High school diploma or equivalent.

Minimum Experience: Two to five (2-5) years of experience preferred. Previous credentialing experience with IPA / Medical Group / Hospital experience required. Must be proficient in Excel and Word skills.

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 http://pmh.com/careers/ 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: https://www1.eeoc.gov/employers/poster.cfm

Keywords: Credentialing, Credentials, Coordination, Coordinator, Medical Policy, Database Entry, Input Data.