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Job description

SUMMARY

The Credentialing Supervisor is responsible for leading, coordinating, monitoring, and maintaining the credentialing and re-credentialing process. Facilitates all aspects of medical group credentialing, including initial appointment, reappointment, expired processes, as well as clinical privileging for Medical Staff, Allied Health Professionals, and all other providers outlined in the medical group’s Bylaws, policies, or related contracts. Ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing. Responsible for the accuracy and integrity of the credentialing database system and related applications. Maintains up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications. Works under the supervision of the Vice President of Provider Network Operations.

ESSENTIAL DUTIES AND REPONSIBILITIES

Leads, coordinates, and monitors the review and analysis of practitioner applications and accompanying documents, ensuring applicant eligibility. Ensure application timeliness per NCQA requirements.

Conducts thorough background investigation, research and primary source verification of all components of the application file.

Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up. Contact practitioners to clarify discrepancies.

Prepares credentials file for completion and presentation to the Credentialing Committees, ensuring file completion within time periods specified. Collaborate with the Chair of the Credentialing Committee to ensure that all significant malpractice cases, state/federal sanctions, and quality issues are reviewed prior to the Credentialing Committee.

Processes requests for privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.

Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.

Assists with delegated credentialing audits; conducts internal file audits.

Utilizes the CVO (Credentialing Verification Organization) credentialing database, optimizing efficiency, and performs query, report and document generation; submits and retrieves National Practitioner Database reports in accordance with Health Care Quality Improvement Act.

Monitors the initial, reappointment and expiring processes for all medical staff, Allied Health Professional staff, Other Health Professional staff, and delegated providers, ensuring compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state), as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated contracts.

Submit all required reports to contracted Health Plans in the allocated time frame

Arranges, organizes, and coordinates the Credentialing Committee meetings including:

Email reminders to members to ensure a quorum.

Prepare agendas, files and needed materials

Assemble meeting packets and/or adhoc meetings.

Plan and schedule meeting space and order catering for meeting

Take minutes, complete follow up correspondence, and send out all Provider communication regarding decisions made by the Credentialing Committee with approval from the Board meeting

Oversees and responds to Health Plan audits and Corrective Action Plans in a

timely manner.

QUALIFICATIONS:

• Minimum 5 years of experience with 4 years directly related to hospital medical staff or managed care credentialing.
• Certification/Licensure NAMSS Certification as a Certified Professional Medical Services Manager (CPMSM) or Certified Provider Credentials Specialist (CPCS) or actively pursuing certification.
• Completed degree(s) from an accredited institution that are above the minimum education requirement may be substituted for experience on a year for year basis.

· Knowledge of CMS, DHCS, DMHC, NCQA standards and Title XXII standards required.

· Knowledge of commonly used concepts, practices and procedures used in health care credentialing.

· Sound knowledge and understanding of Credentialing Committee process.

· Possess excellent organizational skills and attention to detail.

· Ability to maintain strict adherence to deadlines.

· Ability to function well within a team environment and independently.

· Ability to communicate effectively, both orally and in writing.

· Program planning and implementation skills.

· Knowledge of related accreditation and certification requirements.

· Knowledge of medical credentialing and privileging procedures and standards.

· Ability to analyze, interpret and draw inferences from research findings, and prepare reports.

· Working knowledge of clinical and/or hospital operations and procedures.

· Informational research skills.

· Ability to use independent judgment to manage and impart confidential information.

· Database management skills including querying, reporting, and document generation.

· Ability to make administrative/procedural decisions and judgments.

PHYSICAL DEMANDS

• Constant and close visual work at a desk or computer.
• Constant sitting and working at a desk.
• Constant data entry using a keyboard and/or mouse.
• Constant use of telephone headset.
• Frequent verbal and written communication with Providers, internal staff and other business associates by telephone, correspondence, or in person.
• Frequent walking and standing.
• Lifting infrequent, up to 25 lbs. weight.
• Current CA driver’s license and insurance
• Driving to Client locations.

Job Type: Full-time

Pay: $73,000.00 - $88,227.00 per year

Benefits:

• 401(k)
• 401(k) matching
• AD&D insurance
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Life insurance
• Paid time off
• Parental leave
• Tuition reimbursement
• Vision insurance

Schedule:

• Day shift
• Monday to Friday

Supplemental pay types:

• Bonus pay

Work Location: In person