Credentialing Specialist II

Job Summary

The Credentialing Specialist II is responsible for managing their workload, addressing all functions for initial and re-credentialing of Health Delivery Organizations (HDOs) and initial and re-credentialing of applicants in accordance with departmental policies and procedures, National Committee for Quality Assurance (NCQA), Centers for Medicare and Medicaid Services(CMS), California Department of Health Care Services (DHCS) requirements. This incumbent ensures data accuracy of incoming applications and re-credentialing review forms, monitoring data into Visual Cactus. Committee preparation which includes reporting, analysis, and meeting monthly deadlines. All expiries must be maintained and current. Any providers or practitioners identified as having any expired documents must be recommended for removal from the network per policies and procedures. Provider and practitioner data must be accurate and current in our Cactus database. 

Duties

Ensures all applications are complete and conducts primary source verifications, identifies potential adverse events, requesting additional supporting documentation, data entry into CACTUS, prepares files for auditors QA before presenting to Credentialing Committee for decision, generating 60 day letter, scanning into Dynafile and notification to PNO.

Conducts Quality review of profiles, contract, W9 received from delegates through the PCDW application to ensure practitioner meets all regulatory requirements before being added into the network.

Monitors expiring monthly primary source verifications, scans updates into Dynafile and updates data in CACTUS, works with Auditors when potential adverse events, and/or expiring are not renewed, to review and initiate next steps.

Educates and disseminates credentialing information & regulations to delegated entities.

Performs other duties as assigned.

Duties Continued

Education Required

Education Preferred

Experience

Required:

At least 1 year of experience in a healthcare/ managed care environment with 1 year of credentialing or in a credentialing related experience.

Skills

Required:
Ability to audit data and make changes as appropriate with proper documentation.

Ability to audit, retrieve files/documents from our IPA and medical groups at any given time.  

Strong knowledge of the oversight process and ability to apply requirements as per policies and procedures and instruct delegates which includes the Adds, Change, Delete (ACD) process and primary source verifications of all required elements i.e. Board Certification, License, DEA, CHDP, M/M Sanctions.  

Confidentiality is crucial. 

Professional computer skills. 

Excellent communication skills (both verbal and written), high aptitude, and a facility for working on a variety of projects which require the ability to prioritize and re-prioritize, quality assurance review of credentialing files, or have a strong ability to learn.  

Licenses/Certifications Required

Licenses/Certifications Preferred

Required Training

Physical Requirements

Additional Information