Sr Credentialing Coordinator

Job Description

The Credentialing Department provides Credentialing services for practitioners affiliated with Prospect Medical. The Sr. Credentialing Coordinator position performs credentialing and re-credentialing activities according to Prospect Medical Credentialing policies, contracted health plan policies, CMS, state law, and NCQA accreditation guidelines. This position acts as a liaison between our IPAs and contracted health plans to perform any credentialing needs as needed.

Responsibilities

• Review practitioner and organizational provider credentialing and re-credentialing applications for completeness.
• Review and analyze credentialing documents, including education, residency and fellowship training, board certification and eligibility, licensure, professional work history, liability insurance, requests for clinical privileges, malpractice history, and accreditation.
• Assess completeness of information and provider’s qualifications relative to established standards.
• Determine appropriate verification and reference letters to be prepared for adequate processing of each individual application and reapplication.
• Identify and flag adverse information from provider application materials for the purpose of conducting follow-up investigations.
• Request facility site reviews from appropriate sources (i.e. CalOptima) on applicable providers.
• Responsible for completion of re-credentialing files within a 36-month timeframe.
• Update new information as received via re-credentialing process.
• Maintain and exceed quantity and quality goals and standards set by the department.
• Lead role in ensuring that Ongoing Monitoring Reports are reviewed within a 30-day cycle as required and that all required steps are taken and attested to by monitored providers.
• Lead role in responding to all health plan ongoing monitoring inquiries in a timely manner.
• Perform self-audits on all files processed prior to QA review.
• Prepare summary packets for Credentialing Committee review on all files not meeting the Clean File Criteria.
• Semi-annual and quarterly reports.
• Additional Responsibilities for Credentialing Coordinator as assigned including assisting with Committees and reporting.
• Obtain and verify expired documents including licensure, board certification, and liability insurance.
• Support training of new staff members.
• Utilize system reporting to identify areas for improvement and work with the Credentialing Manager and Trainer to establish new/updated policies and procedures.
• Lead credentialing projects to ensure timeliness of application processing, system data integrity, and compliance with all required standards, policies, and laws.
• Demonstrate and maintain credentialing knowledge. Keep abreast of new and changing regulations and standards.
• Follow and abide by departments Policies and Procedures
• Other duties as assigned.
  
  

Qualifications

Minimum Education: High school diploma or equivalent.

Minimum Experience: 2-5 years of experience in credentialing. Requires a dynamic person with the ability to work in a fast-paced environment. Excellent written/verbal and organization skills required. Must be proficient in Excel and Word skills. Preferred proficiency in Adobe Acrobat Professional. Must be highly organized with excellent attention to detail and clerical accuracy. Must be self-motivated with the ability to complete projects independently within established timeframes. Previous credentialing experience with IPA/Medical Group utilizing NCQA standards preferred.

Req. Certification/Licensure: NONE.

"Location-Based Pay Adjustment"

About Us

With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.