Credentialing Specialist

Dignity Health Bakersfield , CA 93301

Posted 4 months ago

Overview

The purpose of Dignity Health Management Services Organization (Dignity Health MSO) is to build a system-wide integrated physician-centric, full-service management service organization structure. We offer a menu of management and business services that will leverage economies of scale across provider types and geographies and will lead the effort in developing Dignity Health's Medicaid population health care management pathways.

Dignity Health MSO is dedicated to providing quality managed care administrative and clinical services to medical groups, hospitals, health plans and employers with a business objective to excel in coordinating patient care in a manner that supports containing costs while continually improving quality of care and levels of service. Dignity Health MSO accomplishes this by capitalizing on industry-leading technology and integrated administrative systems powered by local human resources that put patient care first.

Responsibilities

Responsible for all credentialing activities associated with all IPAs and product lines managed by Dignity Health Management Services Organization. Works with Credentialing Supervisor, Medical Directors, Provider Relations Department, Contracting Department, health plans, providers, provider office staff, and other persons or businesses as necessary to ensure that all providers are properly credentialed according to NCQA and health plan standards.

Where appropriate, makes recommendations regarding improvement of processes and procedures. Will support any additional volume and guarantee the timely processing of files and meeting with DHMSO's turnaround time expectations. Responsible for meeting all of the Dignity Health Management Services Organization Job Standards described below.

Keep current on all NCQA and health plan credentialing standards, policies, and procedures. Attend ICE Credentialing Shared Audit Team Workshops and Teleconferences on a monthly basis to keep informed of current and changing credentialing requirements and standards. Relay information to QM & Credentialing Supervisor for implementation and updates to Policies and Procedures.

Maintain access to all Primary Source Verification websites. Maintain Credentialing Policies and Procedures binders for all product lines associated with Dignity Health Management Services. Coordinate transfer of initial provider credentialing application to Credentials Verification Organization (CVO). Monitor CVO performance of initial and recredentialing on a regular basis for evaluation and intervention, if necessary, to ensure compliance with internal credentialing time frame requirements for all IPAs.

Collect re-credentialing applications and associated required documents from providers who are listed on the 3rd Recred Apps Sent Report posted on CVO website. Upon receipt, forward to CVO for processing. Review all applications returned by CVO for accompanying documents and completeness.

Request additional information from CVO or provider as needed. Reconcile monthly statement from CVO and forward to Finance Department with payment request. Notify CVO if statement is inaccurate and adjustments need to be made prior to forwarding to finance for payment.

Perform internal primary source verifications and full credentialing for those providers who are to be credentialed on a RUSH basis. RUSH status is to be determined by administration including CEO and Medical Directors. Notify Provider Relations Department of need for site visits.

Provide Site Visit Audit Tool and copies of Physician Office Policies and Procedures for Provider Relations to give to new providers at time of site visit. Prepare and forward completed credentialing packets to Medical Director, QM Committees, and Boards of Directors within specified time frames as required.

Complete and forward all appropriate credentialing information to health plans.

Credentialing information includes but is not limited to provider adds, terms, logistical changes, and TIN changes. Maintain electronic correspondence files of notifications of provider information to health plans and internal staff. Keep all credentialing files and credentialing database current and complete.

Attend all meetings pertaining to provider credentialing and provider network management as assigned, including but not limited to Provider Information Meetings sponsored by Provider Relations Department on a quarterly basis, QM & Credentialing Committee meeting for Dignity Health Management Servies Organization and MasterCare IPA Board of Directors. Work with Provider Relations Department to establish agenda items for credentialing updates. Make credentialing updates presentation at provider information meetings if required.

Prepare agenda documents for QM & Credentialing Committees and Board of Directors meetings, including but not limited to Dignity Health Manageemnt Services, MasterCare IPA, and GHP CPRC. Documents include but are not limited to Credentialing Files Review List, Sanction and Disciplinary Action Monitoring Reports, Health Plan Activity Reports pertaining to health plan credentialing updates and audits. Send quarterly and/or semi-annual credentialing reports to all health plans as required.

Coordinate delegated credentialing audits performed by contracting health plans. Duties include but are not limited to scheduling, providing provider rosters, pulling files for review, interacting with auditors on site during the audit, and participating in the exit interview to receive audit outcomes. Maintain health plan correspondence files regarding credentialing updates of any kind and audit outcomes.

Keep copies of corrective action plans and documentation that those CAPs have been accepted by the health plans.

Coordinate credentialing activities with Supervisor as needed, and keep supervisor informed of status of credentialing activities on a regular basis. Perform other duties as assigned.

Qualifications

Strong written and verbal communication skills, excellent organizational skills, and proficient in Microsoft Word, Excel, and Microsoft Outlook. Self-directed and able to work independently under tight time frames. Able to interact with co-workers, managers, supervisors, and administrators in a manner that promotes a positive work environment.

High school diploma or equivalent required, with one or more years of vocational or college coursework preferred. Three to five years of experience in the healthcare industry required, preferably with experience in credentialing. CPCS or CMSC, or progressing towards certification preferred.

Support the mission, vision and strategic goals of Dignity Health Management Services Organization and the department. Attend and participate in required meetings and developmental (training) activities.

Maintains all certifications or licensing required by the job. Adhere to all DHMSO policies and procedures as well as departmental policies and procedures. Maintain strict confidentiality at all times.

Perform duties in a manner that ensures compliance with all current laws and regulations (HIPAA, etc.). Able to adapt to new concepts, ideas and changes in work processes and the work environment. Perform all work in a safe manner and within established safety guidelines. Must be able to concentrate and focus in a moderately noisy work environment.



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Credentialing Specialist

Dignity Health