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Credentialing Coordinator

1 month ago

San Jose, California, United States Santa Clara Family Health Plan Full time
Credentialing Coordinator Role

At Santa Clara Family Health Plan, we are seeking a highly skilled Credentialing Coordinator to join our team. This role is responsible for ensuring the accurate and timely processing of practitioner and vendor credentialing applications, in accordance with state and federal regulatory standards and guidelines.

Key Responsibilities:

  1. Collaborate with providers, SCFHP staff, delegated partners, and stakeholders to manage and execute 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 credentialing data in Credentialing Verification Organization's web-based portal for directly contracted providers, monitor the portal daily, and conduct bi-annual reconciliation of active providers in the portal against the active providers in SCFHP's core operating system.
  4. Represent SCFHP as the primary liaison in 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, conducting sanction and license verifications, maintaining a log of applicants, efficiently gathering network comparison data, and creating and presenting a packet of 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 compliance with applicable license and participation with State and federal programs, and 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, and 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 coordinating meetings, tracking actionable items, documenting minutes, and sending 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 reports and submit audit results to providers, vendors, 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 drafting contracts, LOAs, termination notices, and researching claims data.
  13. Provide back-up support for maintaining provider data and contributing to ongoing data integrity by participating in the provider data attestation process and working with the 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.

Requirements:

  1. Bachelor's degree in Healthcare Administration, Business, Social Sciences, or a related field; or equivalent experience, training, or coursework.
  2. Certification as a Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) is desired.
  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.
  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.
  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.
  6. Experience designing, developing, and conducting training programs is desired.
  7. Proficient in adapting to changing situations and efficiently alternating focus between tasks to support the department's operations as dictated by business needs.
  8. Efficiently operate all applicable computer software, including Microsoft computer applications Word, Excel, and PowerPoint.
  9. Ability to use a keyboard with moderate speed and high level of accuracy.
  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.
  11. Ability to think and work effectively under pressure and accurately prioritize and complete tasks within established timeframes.
  12. Ability to assume responsibility and exercise good judgment when making decisions within the scope of the position.
  13. Ability to maintain confidentiality.
  14. Ability to comply with all SCFHP policies and procedures.
  15. Ability to perform the job safely and with respect to others, to property, and to individual safety.

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.
  2. Lifting Requirements: regularly lift and carry files, notebooks, and office supplies that may weigh up to 5 pounds.
  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.
  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.
  5. Hearing/Talking Requirements: ability to hear normal speech, hear and talk to exchange information in person and on telephone.
  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.

Environmental Conditions:

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

EOE