Credentialing Specialist

L.A. Care Health Plan Los Angeles , CA 90009

Posted 1 week ago

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents.

We are the nation's largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care's mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

Job Summary

The Credentialing Specialist is responsible for managing their workload, addressing all functions for initial and re-credentialing of Health Delivery Organizations (HDOs) and initial and re-credentialing of applicants in accordance with departmental policies and procedures, NCQA, CMS, DHCS requirements. This incumbent will ensure data accuracy of incoming applications and re-credentialing review forms, monitoring data into Visual Cactus.

Committee preparation which includes reporting, analysis, and meeting monthly deadlines. All expiries must be maintained and current. Any providers or practitioners identified as having any expired documents must be recommended for removal from the network per policies and procedures. Provider and practitioner data must be accurate and current in our Cactus database.

Duties

Ensures all applications are complete and conducts primary source verifications, identifies potential adverse events, requesting additional supporting documentation, data entry into CACTUS, prepare file for auditors QA before presenting to Credentialing Committee for decision, generating 60 day letter, scanning into Dynafile and notification to PNO. (35%)

Conducts Quality review of profiles, contract, W9 received from delegates through the PCDW application to ensure practitioner meets all regulatory requirements before being added into the network. (35%)

Monitor expiring monthly conducts primary source verifications, scan updates into Dynafile and update data in CACTUS, work with Auditors when potential adverse events, and/or expiring are not renewed, to review and initiate next steps. (10%)

Educate and disseminate credentialing information & regulations to delegated entities. (10%)

Perform other duties as assigned. (10%)

Education

Associate's Degree or Bachelor's Degree

High School

Experience

With High School Diploma/GED: At least 3 years of experience in a healthcare/ managed care environment with 1-2 years of credentialing or in a credentialing related experience.

Preferred:

With Associate's Degree: At least 1-2 years of experience in a healthcare/ managed care environment with 1-2 years of credentialing or in a credentialing related experience.

Skills

Required:

Ability to audit data and make changes as appropriate with proper documentation.

Ability to audit, retrieve files/documents from our IPA and medical groups at any given time.

Strong knowledge of the oversight process and ability to apply requirements as per policies and procedures and instruct delegates which includes the Adds, Change, Delete (ACD) process and primary source verifications of all required elements i.e. Board Certification, License, DEA, CHDP, M/M Sanctions.

Confidentiality is crucial.

Professional computer skills.

Excellent communication skills (both verbal and written), high aptitude, and a facility for working on a variety of projects which require the ability to prioritize and re-prioritize, quality assurance review of credentialing files, or have a strong ability to learn.

Professional Certification

Preferred:

Certified Medical Staff Coordinator (CMSC).

Certified Provider Credentialing Specialist (CPCS).

L.A. Care offers a wide range of benefits including

  • Paid Time Off (PTO)

  • Tuition Reimbursement

  • Retirement Plans

  • Medical, Dental and Vision

  • Wellness Program

  • Volunteer Time Off (VTO)

Nearest Major Market: Los Angeles

Job Segment: Medical, Healthcare Administration, Data Entry, Healthcare, Administrative



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Credentialing Specialist

L.A. Care Health Plan