Credentialing Specialist

Imperial Health Plan of California, Inc.; Pasadena (CA); On-site; USD 52,000 - 70,000; Full time

Job summary

Imperial Health Plan of California, Inc. is seeking a Credentialing Specialist to handle high volumes of initial provider applications in compliance with CMS and NCQA standards.

You will verify information, manage CAQH and tracking databases, and liaise with providers and health plans to ensure timely credentialing and re-appointments.

Strong knowledge of credentialing terminology and documentation, plus proficiency in MS Office and electronic systems, is essential.

Qualifications

• High school graduate with credentialing experience preferred.
• Proficient with CAQH and Primary Source Verification processes.
• Experience maintaining provider data accuracy and regulatory compliance.

Responsibilities

• Process high volume of initial provider applications per policy.
• Verify information using primary sources and document adverse actions.
• Review applications for Credentialing Committee approval.
• Maintain provider files with current licenses and certifications.
• Coordinate with staff to obtain necessary information for IPA's.
• Manage CAQH and credentialing tracking databases.
• Prepare credentialing documentation for committees and risk management.

Skills

MS Office

Excel

Adobe Acrobat

English communication

Time management

Prioritization

HIPAA compliance

Education

High school diploma or equivalent

Tools

CAQH

ICE Checklist

Primary Source Verification systems

Job description

Job Description

JOB TITLE: Credentialing Specialist FLSA STATUS: Non-Exempt

DEPARTMENT: Credentialing

REPORTS TO: Credentialing Manager

JOB SUMMARY: Responsible for processing high volume of initial provider applications, including Allied Health Professionals in accordance with departmental policies and procedures, CMS and NCQA standards. Ensures interpretation and compliance with the appropriate credentialing regulations. Responsible for the accuracy and integrity of the CAQH and credentialing tracking databases. Acts as the liaison between the credentialing services and providers/health plans.

Essential Job Functions

• Completes all applications using primary source verifications.
• Identify any adverse actions from provider and document for review.
• Review completed applications for submission to Credentialing Committee for approval.
• Ensures that all provider files are complete with current licensing and certification documents.
• When appropriate, works cooperatively with administrative staff to obtain pertinent information necessary for IPA's.
• Possess thorough understanding of credentialing terminology and documents and is able to utilize external systems used to research and obtain pertinent information.
• Manages provider profiles in practice management system.
• Manages IPA coordination for information, and ensures providers are maximized.
• Responsible for the timely gathering and submitting for processing to IPA’s and health plans on an ongoing basis, all credentialing and re-appointment applications.
• Assist provider on completing credentialing application when necessary.
• Tracks all pending applications and notifies the Manager of any challenges with obtaining provider information.
• Responsible for reviewing and verifying all credentialing documentation for providers, confirming consistency and accuracy based on regulatory requirements.
• Coordinates review and approval of clean files by the Medical Director.
• Prepares credentialing documentation for the Risk Management and Compliance Committee.
• Prepares credentialing documents for approval from the Medical Director and Credentialing Committee.
• Assists Manager with credentialing audits.
• Works with all related parties necessary on day-to-day credentialing issues and requests as they arise.
• Maintains accuracy and integrity of the CAQH and credentialing tracking databases.
• Adheres to payroll policies and properly uses timekeeping system with minimal manual changes.
• Maintains regular and consistent attendance.
• Adheres to Compliance Plan and HIPAA regulations.

Marginal Job Functions

• Takes on special projects as needed.
• Performs other duties as assigned.

Behavioral Expectations

• Continuous Learning:
• Attends staff meetings as required.
• Attends appropriate training, seminars and workshops as required
• Customer Focus:
• Maintains client/customer confidentiality and privacy in accordance with HIPPA regulations

and IMAS’s Standards of Conduct.

• Fosters appropriate communication and relations with Supervisor, co-workers and other staff.
• Quality/Process Improvement/Safety
• Reports issues of security, health and/or safety to appropriate supervisor as soon as practicable.
• Supports and demonstrates safety throughout all duties performed.
• Follows established policies and procedures and understands and complies with all regulators

standards set forth by governing entities.

Position Requirements

EDUCATION/EXPERIENCE

• High school graduate or equivalent.
• 2-3 years credentialing experience in a hospital, medical staff office or health plan. Strong CAQH and ICE Checklist experience required. Primary Source Verification experience a plus.

Skills/Knowledge/Ability

• Proficient in the use of Microsoft Office: Word, and Excel
• Proficient in the use of Adobe Acrobat
• Willingness and ability to read, write, speak, understand English and have the communications skills necessary to provide accurate information to members and staff.
• Willingness and ability to follow written and verbal direction in English.
• Willingness and ability to maintain appropriate level of confidentiality and privacy.
• Willingness and ability to interact professionally with all customers, members, and co-workers, individually and as part of a team.
• Willingness and ability to effectively handle multiple items/tasks as required and adapt favorably to changing priorities.
• Willingness and ability to make appropriate judgments, decisions and problem solving in a timely manner and within the context of the situation at hand.
• Ability to effectively prioritize items/tasks as required.
• Willingness and ability to take initiative and be a self-starter.
• Willingness and ability to understand and comply with Federal, State, and local regulations.

Licensure/Certificate/Training

• CPCS or CMSC Certificate is a plus