Credentialing Coordinator

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  • 18-00088
  • Full Time/Contract
  • Credentialing
  • Rancho Cucamonga, CA
Job Description
CLIENT COMPANY OVERVIEW
Our Client is a not-for-profit, rapidly growing Medi-Cal and Medicare health plan serving over 1,138,447 residents of the Riverside and San Bernardino counties. Our client maintains a Positive Team Culture as demonstrated by being voted by Los Angeles News Group readers as "Favorite Overall Company to Work For , "Favorite Training Program , and "Favorite Workplace Culture in their 2014 Winning Workplaces survey.

JOB TITLE
Credentialing Coordinator
Managed Care Health Plan

SUMMARY
Under the direction of the Credentialing Manager, the Coordinator is responsible to coordinate all credentialing activities, to ensure that all contracted providers and delegated providers meet credentialing requirements according to NCQA, state and federal regulatory guidelines.

  • Responsible for complete understanding of NCQA Standards and regulations by CMS, DHCS and DMHC in relation to credentialing requirements and compliance.
  • Responsible for the gathering and researching of credentialing information for the entire provider network.
  • Preparing credentialing documents to be approved by the Medical Director.
  • Timely completion of credentialing packets, which include timely and accurately entering of approved providers into the database and updates of designated providers.
  • Responsible for maintaining the integrity of the Provider data and ensure that the data available for Members, Providers and Team Members is accurate.
  • Preparing documentation for review by the Credentialing & Peer Review Subcommittees.
  • Issue correspondence relating to Credentialing & Peer Review Subcommittee decisions.
  • Assist in review of the Provider Manual policies and procedures.
  • Answer Provider questions related to credentialing process and credentialing status.
  • Complete Spanish Audit and Provider Directory faxes, calls and updates.
  • Assist the Provider Services Department as needed.
  • Monitor and update physician status changes as appropriate.
  • Responsible for making updates received through the provider directory process, into the Network Database System
  • Assist in the review of HIV/AIDS Specialist survey, conducted on an annual basis.
  • Any other duties as required to ensure the Health Plan operations are successful.
  • Support LEAN activities by actively participating in LEAN initiatives, RIEs, huddles, etc.
  • Monitor actions against participating physicians and perform appropriate reporting to State, Federal and regulatory entities.
  • Ensure the privacy and security of PHI (Protected Health Information) as outlined in ‘s policies and procedures relating to HIPAA compliance.

QUALIFICATIONS & EDUCATION

  • Minimum 1-2 years in an office environment, specifically with credentialing applications and experience in a managed care environment. Knowledge of NCQA, state and federal regulatory standards and requirements preferred.
  • Excellent written and verbal communication and interpersonal skills, strong organizational skills, detail oriented.
  • Proficient in Microsoft applications (Microsoft Word, Excel and extensive knowledge in Access).
  • High School Diploma or equivalent required

COMPENSATION | POSITION CLASSIFICATION

  • Commensurate with Experience
  • Full Time | Contract

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