Credentialing Specialist III

Job Category: Provider Relations

Department: Provider Data Management

Location:

Los Angeles, CA, US, 90017

Position Type: Full Time

Requisition ID: 9462

Salary Range: $60,778.00 (Min.) - $75,950.00 (Mid.) - $91,166.00 (Max.)

Established in 1997, L.A. Care Health Plan is an independent public agency created by the state of California to provide health coverage to low-income Los Angeles County residents. We are the nation’s largest publicly operated health plan. Serving more than 2 million members in five health plans, we make sure our members get the right care at the right place at the right time.

Mission: L.A. Care’s mission is to provide access to quality health care for Los Angeles County's vulnerable and low-income communities and residents and to support the safety net required to achieve that purpose.

As a condition of employment, L.A. Care requires a COVID-19 vaccine. This requirement includes our remote workforce. If you would like to request an exemption, L.A. Care has implemented a process to consider exemptions for documented medical conditions and sincerely held religious beliefs. L.A. Care will review all exemption requests prior to proceeding with the recruitment process.

Job Summary

The Credentialing Specialist III is responsible for managing their workload and supporting the Auditors and management in developing and analyzing all functions related to 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 position supports the department in all functions of Committee preparation which includes preparing Committee documents, reports and creating the electronic Committee books. Acts as a Subject Matter Expert, serves as a resource and mentor for other staff.

Duties

Ensures incoming applications are completed timely and analyze primary source verifications, identifies potential adverse events, requesting additional supporting documentation, data entry into CACTUS, prepare files and reports for auditors QA before presenting to Credentialing Committee for decision, generating 60 day letter, scanning into Therefore and notification to PNO.

Develop, analyze and maintain credentialing database reports and reconcile data for internal and external partners. Analyze and update expiring credentialing data through monitoring of reports and conducts primary source verifications. Work with Auditors to research, analyze and prepare case files including providers that do not meet credentialing requirements, potential adverse events, and providers expired credentialing documents that have not renewed to initiate next steps.

Acts as a lead for group projects assigned to Specialists, support Auditors in generating data reports, researching regulatory requirements and support the development of internal processes, desktops and policies.

Supports and assists Auditors in preparing for monthly Credentialing Committee including building the electronic committee book.

As a Subject Matter Expert, developing and conducting training on unit processes, for lower-tiered specialist positions.

Performs other duties as assigned.

Duties Continued

Education Required

Associate's or Bachelor's Degree

In lieu of degree, equivalent education and/or experience may be considered.

Education Preferred

Experience

Required:
At least 0-2 years of experience in a healthcare/ managed care environment with 3-5 years of credentialing or in a credentialing related experience.

Preferred:
At least 5 years of experience in a healthcare/ managed care environment with 3-5 years of credentialing or in a credentialing related experience.

Skills

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

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

Strong knowledge of the oversight process and ability to analyze regulatory and accreditation 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.

Ability to maintain confidentiality is crucial.

Professional computer skills, experience with preparing reports.

Excellent communication skills (both verbal and written), self starter, high aptitude and decisively makes high quality decisions.

Has a facility for working on a variety of projects which require the ability to prioritize and re-prioritize, quality assurance review of credentialing files and have a strong ability to learn and take the lead on projects and assignments.

Proficient skills in credentialing, recredentialing HDOs and practitioners.

Licenses/Certifications Required

Licenses/Certifications Preferred

Certified Medical Staff Coordinator (CMSC)

Certified Provider Credentialing Specialist (CPCS)

Required Training

Additional Information

Salary Range Disclaimer: The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.

L.A. Care offers a wide range of benefits including

Paid Time Off (PTO)
Tuition Reimbursement
Retirement Plans
Medical, Dental and Vision
Wellness Program
Volunteer Time Off (VTO)

At L.A. Care, we value our team members’ safety. In order to keep our work locations safe, each employee is required to self-screen for symptoms prior to entering any L.A. Care location each day. L.A. Care and all of its staff are required to comply with all state and local masking orders. Therefore, when on-site at any L.A. Care location, it's expected that all employees wear a mask in areas where physical distancing cannot be managed.