Credentialing Coordinator

7 days ago

San Jose, United States Santa Clara Family Health Plan Full time
FLSA Status: Non-Exempt
Department: Provider Network Operations
Reports To: Manager, Provider Data, Credentialing and Reporting

Employee Unit: Employees in this classification are represented by Service Employees International Union (SEIU) Local No. 521

GENERAL DESCRIPTION OF POSITION

The Credentialing Coordinator acts as the subject matter expert of Santa Clara Family Health Plan's (SCFHP) Credentialing Department and performs daily operations and activities to ensure practitioner and vendor credentialing applications are processed accurately, timely and in accordance with state and federal regulatory standards and guidelines and SCFHP's policies and procedures. Conduct delegation oversight of any provider partners who are delegated for credentialing activities.

ESSENTIAL DUTIES AND RESPONSIBILITIES

To perform this job successfully, an individual must be able to satisfactorily perform each essential duty listed below.
  1. Work collaboratively with providers, SCFHP staff, delegated partners and stakeholders to manage and execute the initial credentialing and re-credentialing activities for all contracted providers.
  2. Identify areas of risk and/or non-compliance with state and federal regulations and escalate to management in a timely manner.
  3. Enter and manage the required credentialing data in Credentialing Verification Organization's web based portal for directly contracted providers; monitor the portal on a daily basis utilizing online reports; at least bi-annually conduct reconciliation of active providers in portal against the active providers in SCFHP's core operating system.
  4. Represent SCFHP as the primary liaison in the Industry Collaborative Efforts ("ICE") credentialing activities including maintaining a profile on the web portal, participating in meetings, taking minutes, conducting audits and educating the SCFHP Provider Network Management department of new and changing regulatory requirements.
  5. Complete the intake process for potential providers and vendors including verifying the completeness of applications, conduct sanction and license verifications, maintain a log of applicants, efficiently gather network comparison data, create and present a packet of the data for each provider/vendor to the Contract and Credentialing Manager.
  6. Conduct sanction and license verifications for non-contracted providers prior to signing a Letter of Agreement ("LOA"); evaluate provider's compliance with applicable license and participation with State and federal programs; enter provider demographic information and claims payment instructions into SCFHP's provider management databases.
  7. Conduct monthly sanction and license verifications ("Ongoing Monitoring") of all contracted providers (direct or delegated) and vendors in accordance with State and federal requirements and SCFHP's credentialing policies and procedures.
  8. Act as the primary recipient for daily, monthly, quarterly, bi-annual and annual reports from delegated partners; review and confirm accuracy and validity of data; work with Provider Network Management department staff to update provider databases to ensure accuracy of provider data and their participation status (active/inactive/open/closed).
  9. Manage Credentialing Committee meetings including but not limited to coordinate meetings, track actionable items, document minutes, and send regular project and other key communications to stakeholders.
  10. Conduct credentialing oversight audits of all delegated partners and vendors to ensure they are complying with applicable credentialing standards and regulations; use industry standard audit tools and exercise judgment to determine compliance and make recommendations for assigning, processing and closing Corrective Action Plans (CAPs); draft audit report and submit audit results to provider, vendor and the Compliance Department.
  11. Assist in developing, implementing and updating documents related to credentialing activities such as procedures, flow charts, work instructions, audit tools, reports and logs to ensure credentialing activities comply with State and federal requirements and SCFHP credentialing policies and procedures.
  12. Provide back-up support to the Department's contract efforts including but not limited to drafting contracts, LOAs, termination notices and research claims data.
  13. Provider back-up support for maintaining provider data and contributing to ongoing data integrity by participating in the provider data attestation process and working with team to update the provider databases and systems.
  14. Assist in carrying out activities to terminate a provider (administrative or reportable).
  15. Work in collaboration within the department and across other departments on ad hoc, regulatory, and special projects as required.
  16. Perform other duties as required or assigned.
REQUIREMENTS - Required (R)Desired (D)

The requirements listed below are representative of the knowledge, skill, and/or ability required or desired.
  1. Bachelor's degree in Healthcare Administration, Business, Social Sciences or a related field; or equivalent experience, training or coursework (R).
  2. Certification as a Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM). (D)
  3. Minimum two years of experience in managed care or healthcare settings, in positions requiring routine interaction with internal and external stakeholders, one-year of which was in compliance, provider network management, or credentialing role. (D)
  4. Working knowledge of NCQA, Medical Board of California, Business and Professions Code, Health Plan contracts, policies and procedures, and other regulatory rules related to contracting and credentialing and apply them to daily operations. (D)
  5. Ability to think critically, strategically and understand the broad implications of the work being performed in order to consistently meet compliance accuracy and timeline requirements, or provide solutions to achieve regulatory standards. (R)
  6. Experience designing, developing and conducting training programs. (D)
  7. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the department's operations as dictated by business needs. (R)
  8. Efficiently operate all applicable computer software including Microsoft computer applications Word, Excel and PowerPoint. (R)
  9. Ability to use keyboard with moderate speed and high level of accuracy. (R)
  10. Excellent communication skills including the ability to express oneself clearly and concisely when interacting with SCFHP internal departments, members, providers, and outside entities over the telephone, in person or in writing. (R)
  11. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes. (R)
  12. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position. (R)
  13. Ability to maintain confidentiality. (R)
  14. Ability to comply with all SCFHP policies and procedures. (R)
  15. Ability to perform the job safely and with respect to others, to property and to individual safety. (R)
WORKING CONDITIONS

Generally, duties are primarily performed in an office environment while sitting or standing at a desk. Incumbents are subject to frequent contact with and interruptions by co-workers, supervisors, and plan members or providers in person, by telephone, and by work-related electronic communications.

PHYSICAL REQUIREMENTS

Incumbents must be able to perform the essential functions of this job, with or without reasonable accommodation:
  1. Mobility Requirements: regular bending at the waist, and reaching overhead, above the shoulders and horizontally, to retrieve and store files and supplies and sit or stand for extended periods of time; (R)
  2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds; (R)
  3. Visual Requirements: ability to read information in printed materials and on a computer screen; perform close-up work; clarity of vision is required at 20 inches or less; (R)
  4. Dexterity Requirements: regular use of hands, wrists, and finger movements; ability to perform repetitive motion (keyboard); writing (note-taking); ability to operate a computer keyboard and other office equipment; (R)
  5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone; (R)
  6. Reasoning Requirements:ability to think and work effectively under pressure; ability to effectively serve customers; decision making, maintain a concentrated level of attention to information communicated in person and by telephone throughout a typical workday; attention to detail. (R)
ENVIRONMENTAL CONDITIONS

General office conditions. May be exposed to moderate noise levels.

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