Credentialing Specialist at Alignment Healthcare USA, LLC in Orange, California

Job Description:

Overview of the Role:

Alignment Health is seeking an organized and detail oriented credentialing specialist to join the credentialing team. As a credentialing specialist, you are responsible for all aspects of credentialing and re-credentialing for providers, including physicians and healthcare delivery organizations as required. You get to prepare and maintain reports of credentialing activities such as licensure, accreditation, membership or facility privileges. You will also ensure all information meets federal and state guidelines when processing applications as well as maintaining all the records and documentation of the application and verification process. The credentialing specialist works with the providers to maintain current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents as well as maintaining up-to-date data for each provider in credentialing databases and online systems including CAQH.

If you are hungry to learn and grow, want to be part of an expanding healthcare organization, and are passionate about positively impacting the lives of seniors, we're looking for YOU!

Responsibilities:

• Review practitioner and organizational provider credentialing and recredentialing applications for completeness.
• Identify and flag adverse information from provider application materials and perform follow-up investigations.
• Collect, review, and verify provider credentials, including licenses, certifications, education, and work history.
• Coordinate with internal departments and external entities to obtain necessary documentation and information.
• Respond to inquiries from providers regarding their credentialing status.
• Access external websites collecting data for completion of the application process.
• Responsible for the internal data system provider file origination and maintenance and all associated documents storage functions.
• Communicate with credentialing vendors as needed
• Ensure application complies with NCQA and CMS requirements
• Prepare provider and HDO credentialing and re-credentialing files for committee review
• Prepare summary packets for Credentialing Committee review on files not meeting the Clean File Criteria.
• Responsible for health plan provider-related communications.
• Responsible for data accuracy in Credentialing Database and Provider Network application for credentialed contracted providers.
• Know how to process provider applications for hospital privileges for internal staff.
• Maintain good communication with office staff, CVO, hospital staff and physicians. maintains excellent team working skills and working outside of job description if necessary
• Respond to internal and external customer inquiries regarding credentialing status

• Minimum 1 year experience in the field of credentialing in a healthcare environment
• Knowledge of Medicare and Medicare Application processing requirements
• High school diploma, GED, or equivalent
• Some college education a plus
• Certified Provider Credentialing Specialist (CPCS) Credentialing Certificate a plus or willingness to obtain when eligible
• Excellent written and verbal communication skills
• Highly detail oriented
• Proven follow-up skills
• Advanced computer skills including Microsoft Word, Excel, and PowerPoint