Position performs verification and processing of moderately complex to advanced level documents and database information using standard policies, procedures, and guidelines for the coordination, monitoring, and processing of credentialing and re-credentialing of practitioners, providers, mid-levels, allied health professionals and other health care delivery organizations (HDO) based on regulatory, accreditation, contractual and CalOptima standards.
Ensures that the required timely documentation is appropriate and complete for verification processing of practitioners, providers, midlevel, allied health professionals, and other health care delivery organizations for the credentialing and re-credentialing process.
Processes all credential applications, initiates re-credentialing, and/or applications in established electronic file folders.
Initiates primary source verifications and other follow-up as required into the applicant's background, education and experience using online systems, written correspondence, telephone inquiries, and printed reference guides and reports.
Partners with all necessary staff to ensure an integrated, timely, consistent product.
Collaborates with the Provider Relations and Contracting department on the status of candidates to ensure timely credentialing.
Prepares reports as requested. Monitors and maintains reports published by MBOC (Medical Board of California), CMS (Centers for Medicare & Medicaid Services), DHCS (Department of Healthcare Services), OIG (Office of Inspector General) and NPDB (National Practitioner Data Bank), and other applicable sources to identify adverse findings.
Implements an efficient and effective system for the transmission of credential information to internal and external sources to facilitate timely approval in order to participate as a CalOptima approved practitioner, provider or HDO.
Stays aware of changes and updates in laws and regulatory requirements.
Writes and implements desktop policies and procedures as necessary to remain in compliance.
Documents the monitoring of adverse license actions and legal actions.
Other projects and duties as assigned.
Function independently with minimal direct supervision and be detail oriented.
Communicate clearly and concisely, both verbally and in writing.
Accurately and responsively interface and collaborate with all levels of staff and management, contracted committee members, and practitioners with sensitive issues.
Organize credentialing processes and understand and apply credentialing criteria consistently across CalOptima Direct, health networks and physician medical groups.
Maintain confidentiality of peer review information.
Utilize and access computer and appropriate software (e.g. Microsoft: Word, Outlook, Excel, Access and PowerPoint) and job-specific applications/systems to produce correspondence, charts, spreadsheets, and/or other information applicable to the position.
Experience & Education:
High school diploma or equivalent required. College degree preferred.
2 years of experience with credentialing in a hospital or ambulatory setting, such as health plan, medical group or IPA, required.
Certification as Certified Provider Credentialing Specialist (CPCS) preferred.
Federal and State regulatory requirements and accreditation standards: NCQA (National Committee for Quality Assurance), The Joint Commission, DHCS, DMHC, CMS, and other relevant or accreditation certifying agencies.
Job Location Orange, California, United States Position Type Full-Time/Regular