Credentialing Specialist

RiseMe; French Camp (CA); Hybrid; USD 95,000 - 125,000; Full time

Benefits offered by this job

Robust health coverage

Wellness programs

Dental and vision plans

Paid time off and holidays

CalPERS retirement program

Remote work flexibility

Job summary

Health Plan of San Joaquin is seeking a Credentialing Specialist Lead to coordinate daily operations of the Credentialing unit and ensure adherence to HPSJ guidelines and contract standards. This role drives workflow improvements, prepares for audits, and supports credentialing software enhancements while guiding staff and collaborating with internal stakeholders.

The position requires strong knowledge of credentialing standards, regulatory frameworks, data reporting, and excellent

Qualifications

• HS Diploma or equivalent and at least one year as a credentialing specialist.
• Experience with Medi-Cal/Medicare or similar programs preferred.
• Knowledge of NCQA, DHCS, DMHC and CMS credentialing standards.
• Ability to read complex guidelines and maintain documentation accuracy.
• Experience leading training and coordinating audits or committee meetings.

Responsibilities

• Coordinate daily credentialing operations and ensure regulatory compliance.
• Collaborate across departments to improve workflow and processes.
• Prepare and maintain data collection, reporting, and ad hoc analyses.
• Lead credentialing committee activities and distribute packets.
• Support audits, corrective action plans, and CACTUS system enhancements.
• Identify training needs and deliver routine training.

Skills

Credentialing knowledge

Regulatory compliance

Data analysis

Communication skills

Time management

Team leadership

Training delivery

Education

HS Diploma or equivalent

One year credentialing experience

Tools

Credentialing software

Microsoft Word

Microsoft Excel (pivot)

Job description

What You Will Be Doing:

Under general supervision, the Credentialing Specialist Lead coordinates the daily operations of the Credentialing unit and conducts credentialing activities consistent with HPSJ guidelines and contractual and regulatory standards. Work is occasionally varied and minimally to moderately complex and requires a limited to moderate degree of discretion and independent judgment.

Essential Functions:

• Monitors credentialing activities on a daily and weekly basis to ensure compliance with HPSJ and regulatory and contractual standards; resolves routine workload and other issues; makes recommendations on more complex issues.
• Collaborates with interdepartmental units to establish and improve workflow and processes: identifies issues and opportunities; resolves issues or makes recommendations as required.
• Sets up and maintains data collection and reporting systems; inputs data as required; produces routine and AdHoc reports.
• Implements and maintains credentialing department guidelines, policies and procedures and communicates changes to appropriate individuals in a timely and effective manner; makes recommendations for revisions.
• Resolves or facilitates resolution of the most complex credentialing issues.
• Assists with the revisions and enhancements of CACTUS software and other tools.
• Identifies training needs and opportunities; assists in developing and delivering routine and ad hoc department training.
• Prepares for and participates in regulatory audits; gathers information, maintains required reports, develops and monitors timely and effective corrective actions plans.
• Assists the Quality Improvement Department with facility site reviews (FSRs) and maintains FSR aggregate.
• Reviews and verifies credentialing and recredentialing documentation for accuracy, and compliance with HPSJ policies and other mandated standards
• Conducts and obtains credentialing verifications submits completed profiles to Medical Director for review; prepares for submission to Peer Review/Credentialing Committee.
• Coordinates the Peer Review/Credentialing Committee meeting by preparing agendas, compiling, assembling and distributing packets, reviewing minutes for accuracy. Follows-up on Action Items generated by the committee members at the Peer Review/Credentialing Committee Meeting.
• Notifies providers of outcomes of credentialing process; notifies appropriate internal and external stakeholders of provider status changes according to established internal timelines.

What You Bring:

Knowledge, Skills, Abilities and Competencies

Required

• Produces work that is accurate and complete.
• Produces the appropriate amount of work.
• Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
• Rebounds from setbacks and adversity when facing difficult situations.
• Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
• Strong knowledge of NCQA, DHCS, DMHC, Centers for Medicare and Medicaid Services (CMS) credentialing standards and principles of managed care.
• Strong knowledge of credentialing software systems.
• Strong knowledge of record keeping principles and techniques.
• Strong knowledge of practitioner verification requirements and data base systems.
• Strong knowledge of audit processes, and the ability to effectively implement and maintain them.
• Ability to read, interpret and apply complex written guidelines, instructions and other materials.
• Strong planning and organizational skills with the ability to effectively prioritize multiple tasks.
• Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
• Strong oral and written communications skills with the ability to communicate persuasively to diverse individuals inside and outside of HPSJ.
• Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
• Good presentation skills.
• Ability to use tact and diplomacy to diffuse emotional situations.
• Strong facilitation, problem solving and conflict resolution skills, with the ability to use tact and diplomacy to diffuse emotional situations.
• Ability to commit to and facilitate an atmosphere of collaboration and team work.
• Ability to gather and compile data and information, and perform simple analysis.
• Ability to work independently and as part of a team.
• Ability to speak and be understood in English.
• Type 50 WPM at 90%.
• Strong customer service skills.
• Ability to assist developing and delivering relevant and effective training and supporting materials.
• Intermediate skills in Word and Excel, including the ability to create formulas and pivot tables.
• Basic mathematics skills.
• Ability to speak and be understood in English.
• Commitment and demonstrated ability to act as a role model for HPSJ’s vision, mission and values.
• Ability to handle confidential information with appropriate discretion.

What You Have:

Education and Experience

Required

• HS Diploma or equivalent.
• At least one year as a credentialing specialist.

Preferred

• Experience working with Medi-Cal and/or Medicare, or other state or federally sponsored programs.
• Experience working in a Medical managed care setting.

What You Will Get:

HPSJ Perks:

• • Robust and affordable medical coverage including HMO and PPO plan options
  • Employee Wellness Program promoting physical, mental, and financial well-being
  • Dental and vision plan with multiple provider choices
  • Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays, and 9 paid holidays)
  • CalPERS retirement pension program, automatic employer-paid retirements contributions, plus a voluntary defined contribution plan
  • Two flexible spending accounts (FSAs)for healthcare and dependent care expenses
  • Employer-Paid Term Life and AD&D Insurance
  • Employer-Paid Disability Insurance
  • Employer-Paid Assistance Program (EAP)
  • Health Advocacy to help you navigate medical care and benefits
  • Voluntary supplemental benefits including medical, legal, identity theft protection
  • Online discount mall
  • Tuition reimbursement
  • Remote work contingent on business needs and company guidelines
  • A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do

At this time, the Health Plan does not sponsor visa. Candidates must have legal and valid work authorization, Green Card, or U.S. citizenship .

Physical Demands

Work may require frequent sitting, standing, and walking, constant repetitive motion, frequent talking and listening, closeup and distance vision requirements. Some work may require occasional travel based on the responsibilities of the position and business needs and occasional handling materials up to 50 pounds.

Emotional/Psychological Demands

Ability to cope with a fast-paced work environment, working under pressure, dynamic priorities and deadlines, constant decision making, working irregular hours, emotional and sensitive situations.

Work Environment

Work may be performed in a remote, hybrid, or onsite setting depending on the requirements of the position and business needs. For roles performed remotely, employees are expected to maintain a secure, distraction-free workspace, and reliable internet connectivity consistent with company standards.

Important Notice: The duties, qualifications, and physical and emotional requirements listed in this job description are not exhaustive. Health Plan of San Joaquin reserves the right to revise this job description at any time.