Lead Credentialing Coordinator & Trainer

Job Summary

This position performs and supervises credentialing and recredentialing activities according to Prospect Medical Credentialing Policies, contracted health plan policies, CMS, state law, and NCQA accreditation guidelines.

Credentialing & Recredentialing

• Review practitioner and organizational provider credentialing and recredentialing 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 source (i.e. CalOptima) on applicable providers.

• Responsible for completion of recredentialing files within 36-month timeframe.

• Update new information as received via recredentialing process.

• Maintain and exceed quantity and quality goals and standards set by the department.

• Other duties as assigned by Management.

Compliance & Oversight

• Oversight 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.

• Oversight role in responding to all health plan ongoing monitoring inquiries in a timely manner.

• Perform self-audits as well as audits on all files processed by trainees prior to QA review.

• Prepare summary packets for Credentialing Committee review on files not meeting the Clean File Criteria.

• Semi-annual and quarterly reports.

• Credentialing Committee coordination, prep, and presentation backup to Manager.

• Additional Responsibilities as assigned including assisting with Committees and reporting.

• Demonstrate and maintain credentialing knowledge. Keep abreast of new and changing regulations and standards.

Training

• Ownership of new staff training.

• Maintain tracking of trainee progress and reports to Manager.

• Create and update SOPs/tools to ensure continued compliance and process improvements.

Job Knowledge, Skills and Abilities

To perform this job successfully, an individual must be able to perform the job description satisfactorily. This job description reflects management's assignment of essential functions, it does not prescribe or restrict the tasks that may be assigned. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

• 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 Nuance/Kofax Power PDF Advanced.

• 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.

Required Education/Experience

• High school diploma or equivalent.
• 5+ years of experience in credentialing.

Preferred Education/Experience

• Previous credentialing experience with IPA/Medical Group utilizing NCQA standards.