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Credentialing Specialist in Orange at Prospect Medical Systems

Date Posted: 4/26/2018

Job Snapshot

Job Description



Credentialing Specialist

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 Department provides Credentialing services for practitioners affiliated with Prospect Medical. This position serves as the central facilitator of the receipt, triage and assignment of credentialing and re-credentialing applications and the process of notifying network providers regarding their impending credential to assure compliance with NCQA, CMS, DHS, and health plan credentialing requirements. Also responsible for ensuring the accuracy of practitioner data in the Credentialing database program.



Job Responsibilities/Duties

  • Triages, assigns, proactively follows up and closes all Credentialing initial and re-credentialing applications on a timely manner.
  • Process Initial and Re-Credentialing Applications as they come in (includes: reviewing, data entry, assigning to Credentialing Coordinators and following up for missing documents)
  • Responsible for/assures reappointment process is initiated for each practitioner and closed timely in order to meet compliance.
  • Responsible for/assures reappointment process is initiated for each practitioner.
  • Oversee and coordinate credentialing activities with contracted CVO.
  • Reviews and monitors the assignment log and productively report regularly to ensure appropriate assignment and ensure helping department focus on months ahead.
  • Track Re-Cred Applications received using an excel spread sheets and credentialing system notes.
  • Plans, develop, and coordinate activities/procedures to assure compliance with NCQA, CMS, DHS, and health plan requirements.
  • Help follow up with provider offices, help with internal and external credentialing inquiries
  • Productivity and Management Reports.  Accountable for ensuring “programmed” reports meet quality standards and are delivered on time.  Work with IT or reporting resources to deliver on ad-hoc reports, such as new HP reports. 
  • Send credentialing files to the CVO and track progress using excel spread sheets and Credentialing database notes.
  • Ensure all due re-creds are returned on a timely manner and ensure Performance Standards are being met.
  • Follow-up on providers responsiveness/issues found by the CVO
  • Assign the CVO returned files to the coordinators immediately after return and ensure timely completion by using the report.
  • Plan, organize, and coordinate activities with network management team, contracting team and - Credentialing Department.
  • Facilitates initial Credentialing Department administrative functions.


Qualifications

Minimum Education: High school diploma or equivalent.

Minimum Experience: Five (5) years of experience and/or training in credentialing operations in a hospital or IPA setting; or equivalent combination of education and experience.

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: IPA, Credentialing, Medical Group, Health Plans, Specialist, Credentialing Speicalist