Job Summary \n 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. \n Credentialing & Recredentialing \n
\n
Review practitioner and organizational provider credentialing and recredentialing applications for completeness.
\n
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.
\n
Assess completeness of information and provider's qualifications relative to established standards.
\n
Determine appropriate verification and reference letters to be prepared for adequate processing of each individual application and reapplication.
\n
Identify and flag adverse information from provider application materials for the purpose of conducting follow-up investigations.
\n
Request facility site reviews from appropriate source (i.e. CalOptima) on applicable providers.
\n
Responsible for completion of recredentialing files within 36-month timeframe.
\n
Update new information as received via recredentialing process.
\n
Maintain and exceed quantity and quality goals and standards set by the department.
\n
Other duties as assigned by Management.
\n
\n Compliance & Oversight \n
\n
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.
\n
Oversight role in responding to all health plan ongoing monitoring inquiries in a timely manner.
\n
Perform self-audits as well as audits on all files processed by trainees prior to QA review.
\n
Prepare summary packets for Credentialing Committee review on files not meeting the Clean File Criteria.
\n
Semi-annual and quarterly reports.
\n
Credentialing Committee coordination, prep, and presentation backup to Manager.
\n
Additional Responsibilities as assigned including assisting with Committees and reporting.
\n
Demonstrate and maintain credentialing knowledge. Keep abreast of new and changing regulations and standards.
\n
\n Training \n
\n
Ownership of new staff training.
\n
Maintain tracking of trainee progress and reports to Manager.
\n
Create and update SOPs/tools to ensure continued compliance and process improvements.
\n
\n Job Knowledge, Skills and Abilities \n 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. \n
\n
Requires a dynamic person with the ability to work in a fast-paced environment.
\n
Excellent written/verbal and organization skills required.
\n
Must be proficient in Excel and Word skills.
\n
Preferred proficiency in Nuance/Kofax Power PDF Advanced.
\n
Must be highly organized with excellent attention to detail and clerical accuracy.
\n
Must be self-motivated with the ability to complete projects independently within established timeframes.
\n
\n Required Education/Experience \n
\n
High school diploma or equivalent.
\n
5+ years of experience in credentialing.
\n
\n Preferred Education/Experience \n
\n
Previous credentialing experience with IPA/Medical Group utilizing NCQA standards.
\n
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.Previous experience in auditing, Experience with Excel and Access, Astute problem solving skills, Ability to read and comprehend contracts. In depth knowledge of Morrisey and CDA with previous credentialing experience.High School Diploma or GEDResponsible for training all new employees for the first 30 days of employment. Responsible for creating and implementing training material for the Provider Information Management and Credentialing department to all employees are trained in a consistent manner for PIM and Credentialing, to include but not limited to Morrisey, CDA, and Sanator.|Audit new employees work prior to completion within 30 days. Review PID retrieval and re-submission process. Review Change Forms on CDA, Morrisey reports, emails submitted to health plans.|Review of rosters submitted to health plans.|Educates and updates the PIM/Credentialing Department on new guidelines. Resource for training, education and coordination of improvements and additions. Attend weekly meetings.Responsible for training all new employees for the first 30 days of employment. Responsible for creating and implementing training material for the Provider Information Management and Credentialing department to all employees are trained in a consistent manner for PIM and Credentialing, to include but not limited to Morrisey, CDA, and Sanator.|Audit new employees work prior to completion within 30 days. Review PID retrieval and re-submission process. Review Change Forms on CDA, Morrisey reports, emails submitted to health plans.|Review of rosters submitted to health plans.|Educates and updates the PIM/Credentialing Department on new guidelines. Resource for training, education and coordination of improvements and additions. Attend weekly meetings.
