Credentialing Examiner - Remote In CA

Optum is a global organization that delivers care, aided by technology to help millions of people live healthier lives. The work you do with our team will directly improve health outcomes by connecting people with the care, pharmacy benefits, data and resources they need to feel their best. Here, you will find a culture guided by diversity and inclusion, talented peers, comprehensive benefits and career development opportunities. Come make an impact on the communities we serve as you help us advance health equity on a global scale. Join us to start Caring. Connecting. Growing together.

Jobs related to managing provider networks that support client base. This includes hospital, physician, dental, and pharmaceutical networks. Examples include provider relations activities, analyzing provider performance, creating provider reimbursement arrangements, and credentialing activities.

Positions in this function are responsible for all activities associated with credentialing or re-credentialing physicians and providers. Includes processing provider applications and re-applications including initial mailing, review, and loading into the database tracking system ensuring high quality standards are maintained. Conducts audits and provides feedback to reduce errors and improve processes and performance. Responsible for the development of credentialing policies and procedures. May oversee primary source verification activities.

You'll enjoy the flexibility to telecommute* from anywhere within California as you take on some tough challenges.

Primary Responsibilities:

• Oversee/Facilitate/Complete Receipt and Processing of Provider Applications

• Receive and review application and supporting documents (e.g., questionnaire; attestation form; insurance document) to determine if required and necessary information is included

• Determine appropriate teams needed to provide validation of submitted information

• Refer submitted application and supporting documents to internal teams needed to approve or deny entrasnce into networks

• Contact and follow-up as needed with provider and/or request assistance from recruiter team to obtain missing information

• Identify potential process improvement needs to provider application processes

• Provide input into policy changes or updates and/or respond to corrective action requests regarding provider application processes and related documents

• Educate internal and/or external stakeholders regarding application processes (e.g., DEA guidelines; CDS guidelines)

• Distribute files to applicable stakeholders (e.g., credentialing coordinators) to verify and/or enter information into appropriate systems

• Oversee/Facilitate/Complete Analysis and Verification of Provider Credentials

• Review application materials to determine if providers meet internal qualifying criteria for addition and/or continuation in networks

• Ensure providers have appropriate credentials (e.g., state licenses; sanctions; Medicaid/Medicare identifications; hospital affiliation; board certification; malpractice insurance)

• Compare application information to credentialing source (e.g., state licensing website) to ensure accuracy and completeness of provider application information

• Ensure verifications are completed within state, federal, and/or internally-mandated timeframes (e.g., NCQA; URAC; CMS)

• Contact primary sources, credentialing agencies, and/or reference on-line information sources in order to verify provider credential

• information (e.g., licenses; education; Board certifications; DEA and/or CDS)

• Educate and/or consult with internal and/or external stakeholders regarding provider analysis and verification processes and requirements

• Identify potential process improvement needs to provider analysis and verification procedures

• Provide input into policy changes or updates and/or respond to corrective action requests regarding analysis and verification processes and related documents

• Maintain Provider Credentialing Documentation

• Submit, enter and/or update provider information from application, prime source verification, and/or clients into applicable databases (e.g., FACETS; Advantage; CVOne)

• Scan provider credentialing information into applicable systems (e.g., Document Retrieval) to follow document management and retention procedures

• Perform audit of provider file in order to ensure documentation meets state, federal, and industry standards

• Verify that appropriate signatures (e.g., provider; company representatives) on contracts have been obtained and follow corporate signature procedures

• Facilitate/maintain/send correspondence (e.g., welcome letters; termination letters; rejection letters) to providers

• Create/update/provide input into provider documentation procedures, policies, and practices

• Identify potential process improvement needs and/or respond to corrective action requests regarding provider documentation procedures

• Support/Monitor/Oversee Quality of Network Providers

• Monitor credentialing sources to determine if providers should continue within the network

• Receive and/or gather information from applicable databases regarding provider quality and performance (e.g., disciplinary notices)

• Monitor provider credentials to ensure providers remain up to date with state and/or federal guidelines (e.g., NCQA; URAC)

• Review reports (e.g., disciplinary reports; monthly reports; Medicare/Medicaid reports) from state licensing bodies to determine if

• affected providers are within the network and recommend appropriate follow-up actions

• Provide information regarding provider performance issues to the appropriate internal team (e.g., UR/UM; credentialing committee)

• in order to analyze risk and/or determine continued network participation

• Create/update/provide input into procedures, policies, and practices for overseeing provider quality

• Identify potential process improvement needs and/or respond to corrective action requests regarding network provider monitoring procedures

• Pull required files, information, and processes to respond to external audit requests from NCQA, URAC, CMS and/or clients

• Oversee delegated relationships with external partners (e.g., leased partners; hospitals) to ensure credentialing practices are performed in accordance with contractual agreements

• Demonstrate Knowledge of Credentialing Processes, Tools, and Regulations

• Demonstrate knowledge of industry terminology (e.g., medical; dental; behavioral health)

• Demonstrate knowledge of applicable state and federal laws, policies, and regulations (e.g., state-specific license requirements;

• Controlled Dangerous Substances license requirements; DEA)

• Demonstrate knowledge of credentialing procedures, policies, and terminology (e.g., NCQA; URAC)

• Demonstrate knowledge of provider information storage and retrieval systems

• Demonstrate knowledge of computer software applications (e.g., MS Office), systems (e.g., Advantage), and databases (e.g., National Practitioner Data Bank)

• Demonstrate knowledge of key operating indicators (e.g., quality percentages; turnaround time)

You'll be rewarded and recognized for your performance in an environment that will challenge you and give you clear direction on what it takes to succeed in your role as well as provide development for other roles you may be interested in.

Required Qualifications:

• High School Diploma/GED (or higher)

• 3+ years of credentialing experience

• Intermediate level or proficiency with Microsoft Office products

Preferred Qualifications:

• Credentialing Provider Certified Specialist certification

• Experience with the CACTUS Credentialing software

• Previous healthcare experience

Soft Skills:

• Computer literate

• Knowledge of NCQA and AAAHC credentialing standards

• Experience with data entry, word processing and use of menu-driven computer applications

• Strong attention to detail and accuracy

• Proven organizational skills

• Knowledge of the current credentialing system software

• Effective written and verbal communication skills

• Flexibility in accepting and managing multiple tasks

• Ability to work collaboratively as part of a team

• Ability to interface with all levels of management

• Valid California driver's license and the ability to commute between HealthCare Partners sites

• All Telecommuters will be required to adhere to UnitedHealth Group's Telecommuter Policy.

California Residents Only: The hourly range for California residents is $16.54 to $32.55 per hour. Pay is based on several factors including but not limited to local labor markets, education, work experience, certifications, etc. UnitedHealth Group complies with all minimum wage laws as applicable. In addition to your salary, UnitedHealth Group offers benefits such as, a comprehensive benefits package, incentive and recognition programs, equity stock purchase and 401k contribution (all benefits are subject to eligibility requirements). No matter where or when you begin a career with UnitedHealth Group, you'll find a far-reaching choice of benefits and incentives.

Pursuant to the San Francisco Fair Chance Ordinance, we will consider for employment qualified applicants with arrest and conviction records.

At UnitedHealth Group, our mission is to help people live healthier lives and make the health system work better for everyone. We believe everyone-of every race, gender, sexuality, age, location and income-deserves the opportunity to live their healthiest life. Today, however, there are still far too many barriers to good health which are disproportionately experienced by people of color, historically marginalized groups and those with lower incomes. We are committed to mitigating our impact on the environment and enabling and delivering equitable care that addresses health disparities and improves health outcomes - an enterprise priority reflected in our mission.

Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity / Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.

UnitedHealth Group is a drug - free workplace. Candidates are required to pass a drug test before beginning employment.

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