Credentialing Specialist

Job Details

Job Location

Huntington Beach Office - Huntington Beach, CA

Remote Type

Fully Remote

Position Type

Full Time

Description

Wage Range: $25.00/hour - $29.00/hour

Candidate must reside in California, Arizona, Nevada or Oregon.

Job Summary

In collaboration with the Credentialing Supervisor and Chief Medical Officer (CMO), the Credentialing Specialist performs all credentialing activities for Clever Care, including but not limited to the timely and accurate processing of all applications and related documents required to meet regulatory and plan requirements for credentialing. Processes high volume credentialing and re-credentialing applications and/or enrollments of health care providers, responsible for entering, updating, maintaining NPI and any other applicable provider numbers into the system. Reviews applications, prepares verification letters and maintains database. Contacts medical office staff, licensing agencies, and insurance carriers to complete credentialing and re-credentialing applications. Prepares recommendations to the Credentialing Committee based on a review and analysis of practitioner or facility documentations, qualifications, performance and reported practice outcomes.

Functions & Job Responsibilities

• Review, verify, and validate medical documentation, certifications, employment forms, testing, and other requirements to determine qualifications for credentialing have been met and ensure compliance with company credentialing standards.
• Responsible for quality review of all aspects of the enterprise-wide credentialing function and primary source verification process for practitioners and health delivery organizations according to Clever Care policy and procedure. where possible, specific production goals on a weekly or monthly basis will be tracked for each respective accountability.
• Maintaining contact with healthcare professionals and guiding them through the required compliance documentation for assignments.
• Preparing correspondence and communications to obtain information determined to be deficient or missing as part of the application and primary source verification process.
• Accurately gather and input data into the credentialing data into the system.
• Outreach to various medical specialty boards, educational institutions or medical facilities to inquire about practitioner credentials, work history, or other findings related to determining credential qualifications.
• Troubleshooting credentialing team inquiries and issues.
• Meeting with the Credentialing Supervisor to provide ongoing feedback related to department questions, concerns and performance
• Review and assemble necessary document to substantiate provider and facility qualifications for presentation to the Credentialing Committee
• Conduct research on any issues determined to be red flags requiring Medical Director attention and review to ensure issue does not raise liability concerns for the company
• Prepare correspondence to communicate with providers on the status of applications, missing documentation, or follow up on requests for outstanding items.
• Facilitate problem-solving and suggest improvement processes to achieve customer resolution and elimination of current credentialing issues
• Ensures that the Clever Care healthcare provider network consists of providers that meet all regulatory and risk management criteria in order to minimize liability to the company and to maximize safety for members.
• Conducts the quality review of all credentialing files to ensure compliance with policies, procedures and accreditation standards
• verifies the completeness and accuracy of data entry into support systems
• ensures level 2 credentialing files are appropriately prepared for presentation to the credentialing committee
• guides and answers questions from provider relations staff and assists with questions and interdepartmental issues to help coordinate problem solving in an efficient and timely manner
• maintains a high level of confidentiality for provider information
• In the event that Credentialing Supervisor is unavailable, Credentialing Specialist can provide consultation or expert advice regarding credentialing to management.
• Other duties as assigned
  
  

Qualifications

Qualifications

Education & Experience:

• Undergraduate degree or equivalent work experience
• Certified Provider Credentialing Specialist (CPCS) a plus
• Three (3) years of hands-on work experience within Medical Group or Health plan credentialing process
  
  

Skills:

• Knowledge of CMS, NCQA and other credentialing regulations.
• Familiarity with CAQH ProView and/ Intellicred software or automated Credentialing Systems.
• Familiarity with Medical Licensure Board, Joint Commission on Accreditation and other entities used in the primary source verification of quality, education, and training of providers.
• Strong verbal and written communication skills
• Ability to prepare and respond to correspondence in a timely manner.
• Outstanding organizational and management skills.
• Ability to problem solve effectively and be very detail oriented.
• Strong research and analytic skills to research and identify information necessary to validate a provider’s credentials.
• Ability to navigate between multiple data bases quickly and accurately
• Must have ability to work with mathematical concepts, health care acronyms, able to differentiate between provider titles, download the providers applications using the Internet.
• Meet productivity standards as outlined in department metrics
• Ability to Identify any issues or trends and bring them to the attention of management team with recommendation for resolution.
• Extensive experience using a computer -- specifically internet research, Microsoft Outlook, Word, Excel and other software systems.
  
  

Physical & Working Environment.

Physical requirements needed to perform the essential functions of the job, with or without reasonable accommodation:

• Must be able to travel when needed or required
• Ability to operate a keyboard, mouse, phone and perform repetitive motion (keyboard); writing (note-taking)
• Ability to sit for long periods; stand, sit, reach, bend, lift up to fifteen (15) lbs.
  
  

Ability to express or exchange ideas to impart information to the public and to convey detailed instructions to staff accurately and quickly.

Work is performed in an office environment and/or remotely. The job involves frequent contact with staff and public. May occasionally be required to work irregular hours based on the needs of the business.

Clever Care Health Plan is proud to be an Equal Employment Opportunity and Affirmative Action workplace. Individuals seeking employment will receive consideration for employment without regard to race, color, national origin, religion, age, sex (including pregnancy, childbirth or related medical conditions), sexual orientation, gender perception or identity, age, marital status, disability, protected veteran status or any other status protected by law. A background check is required.

Salary ranges posted on the job posting are based on California wages. Salary may be higher or lower depending on the candidate’s state residency.