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Credentialing Coordinator I
2 months ago
Job Description
This position performs credentialing and re-credentialing activities according to Prospect Medical Credentialing Policies, contracted health plan policies, CMS, DMHC, and NCQA accreditation guidelines. This position acts as a liaison between our IPAs and contracted health plans.
Responsibilities
Review all provider credentialing and re-credentialing 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 and malpractice history.
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 special follow-up investigations.
Request facility site reviews from appropriate source (i.e. CalOptima) on applicable providers.
Responsible for the generating, mailing, tracking, and subsequent processing of provider re- credentialing applications. All re-credentialing files are to be completed within 36 month timeframe. Requires following Prospect Medical policy and compliance schedule for sending up to 3 requests starting 6 months prior to credentialing expiration and making follow up calls according to policy.
Update new information as received via re-credentialing process
Maintain and exceed quantity and quality goals and standards set by the department
Maintain 80% accuracy rate on the number of files submitted for the credentialing committee(s).
Responsible for ensuring that Licensing Board Disciplinary Reports are ran and reviewed within a 30 day cycle as required.
Review files processed by Credentialing Coordinator(s) prior to committee review.
HDO reviews and credentialing.
Semi-annual and quarterly reports
Additional Responsibilities for Credentialing Coordinator as assigned including assisting with Committees and reporting.
Qualifications
Minimum Education:
High school diploma or equivalent.
Minimum Experience:
1 or more (1+) years of experience preferred. Previous credentialing experience with IPA / Medical Group / Hospital experience required. Must be proficient in Excel and Word skills.
Req. Certification/Licensure:
None
About Us
With approximately 9,000 physicians to serve our 260,000 members, Prospect Medical Systems is proud to be among the most innovative medical systems in California, Texas and Rhode Island. Our extensive care services range from primary care and specialty physician services to acute care hospital and skilled nursing facilities to behavioral health and wellness services. Each of our Independent Physician Associations (IPAs) and networks support the use of advanced diagnostic and treatment tools to provide our members with convenient access to state-of-the-art healthcare. For 25+ years, Prospect Medical has been focused on our mission of supporting independent physicians where, through risk arrangements, we work closely together with health plans, facilities and healthcare physicians for the benefit of every person who comes to us for care. We provide quality healthcare services that are designed to offer our patients highly coordinated, personalized care and that help them live healthier lives. Prospect Medical Systems manages highly successful IPAs by leveraging our best-practices, results-driven administrative services to manage patients under risk arrangements with health plans/CMS.
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