The position will monitor and lead the credentialing work activities to ensure that standards are met. Reviews credential files for accuracy. Assesses credentialing staff workload; serves as a resource to the credentialing staff regarding CalOptima policies and procedures as well as regulatory and accreditation requirements.
POSITION RESPONSIBILITIES:
- Hires, supervises, trains, reviews, and sets goals for the team and the individual staff.
- Assists manager with coverage of QI department when manager is not readily available.
- Reviews credentialing files to ensure credentialing requirements meet applicable policies and procedures.
- Collaborates with QI Program/Policy Analyst in collection, monitoring and analysis of credentialing activities.
- Works with QI Manager to prepare files and presentations for Credentialing Peer Review Committee.
- Serves as a resource to departmental staff, internal departments, and affiliated health networks regarding credentialing and provider network projects.
- Reviews workflows, procedures, and/or policies and recommend or change items to meet regulatory and accreditation requirements.
- Assists in the development and implementation of credentialing related policies and procedures.
- Identifies and conducts performance feedback and/or counseling/corrective action meetings with the assistance of Human Resources as necessary.
- Assists the QI Manager and QI Director with budget related credentialing activities.
- Prepares for regulatory and internal audits, provides additional information as requested, and develops responses or corrective action plans as required.
- Other projects and duties as assigned.
Required Skills
- Maintain and ensure confidentiality of patient and provider information.
- Communicate effectively both verbally and in writing to diverse audiences.
- Utilize and access computer programs – both Microsoft Office applications and job-specific applications.
- Manage multiple projects and responsibilities with varying levels of priority.
- Encourage and recognize the quality performance and development of subordinate staff.
Required Experience
EXPERIENCE & EDUCATION:
- High School diploma or equivalency; Bachelor’s degree in Health Services, Public Health, Business, or other related field preferred; or equivalent combination of education and experience, highly desirable.
- Certified Provider Credentialing Specialist (CPCS) or similar certification required and 3 years credentialing experience required; or, CPCS preferred and 5 years of credentialing experience required.
- 2 years supervisory experience required.
- Experience in a health care delivery system, such as a health plan, medical group, or hospital required in the State of California preferred.
KNOWLEDGE OF:
- Regulatory and accreditation standards and guidelines- DHCS, DMHC, CMS, Joint Commission, and NCQA.
- Symplr - Cactus Provider Management Platform.
- CAQH Proview.
Grade: L
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