Credentialing Specialist, Santé IPA, Fresno, CA
Posted on February 2nd, 2023
This non-exempt position is responsible for coordinating, monitoring and performing credentials verification process for initial appointments and reappointments of physicians and allied health professionals. Incumbents will be skilled in all aspects of initial comprehensive credentialing, recredentialing, performance monitoring, in accordance with NCQA accreditation standards, state and federal regulatory requirements, and Santé’s credentialing policies and procedures.
Two years relevant experience in physician credentialing. Excellent communication skills both written and verbal, including telephonically, email, and presentation. Ability to work independently with minimal supervision. Ability to establish and maintain effective working relationships with providers, management, staff and contacts outside the organization. Proficient use of Microsoft Office applications. Certified Provider Credentialing Specialist (CPCS) preferred. AA/AS degree preferred.
- Verify competence, medical and/or professional education, residency, internships, fellowships, additional formal training, relevant board certifications, health care affiliations, work history, licensure and certifications, DEA certificates and malpractice coverage.
- Perform and collect all primary source documentation as outlined in the Policies and Procedures for initial credentialing and recredentialing for Santé Physicians IPA.
- Analyze physician practice/specialty parameters for Santé’s business needs and prepare reports for presentation to Board of Directors and Committees for review and approval.
- Actively participates in all required annual audits.
- Keep abreast of all current credentialing/recredentialing mandated guidelines, policies and procedures in order to formulate new and revise current Santé policies and procedures.
- Ensures support, maintenance, and updating of the practitioner credentialing database system.
- Provides quality and ethical customer service to all practitioners, medical group liaisons, and other hospital/healthcare entities.
- Meet all Health Plan quarterly and semi-annual reporting requirements.
- Assist in preparing data for required Committee meetings with the ability to record and transcribe minutes of Committee meetings.
- Review credentialing delegation agreements as presented by current and potential contracted health plans to ensure accuracy of delegation parameters.
- Track adverse licensure actions with the ability to communicate directly with the practitioner (written and verbally); actively participate in QI reviews on adverse licensure issues.
- Orient and train new staff.
- Maintain confidentiality of provider information
Maintain health plan delegation for credentialing by way of successfully passing annual health plan audits. Knowledge of computer program applications including MS Word/Excel/PowerPoint. Knowledge of Santé Credentialing policies and procedures.
ESSENTIAL DUTIES AND RESPONSIBILITIES
- Skill in establishing and maintaining effective working relationships.
- Ability to organize workflow, effectively prioritize, and meet deadlines and objectives.
- Research, analyze and interpret data and present comprehensive reports.
- Ability to communicate clearly and effectively orally and in writing.
- Excellent time management, multi-tasking, and prioritization skills.
- Other functions and accountabilities may be assigned
TYPICAL PHYSICAL DEMANDS
Requires prolonged sitting, some bending, stooping or stretching. Manual dexterity sufficient to operate a keyboard, photocopier, calculator, telephone and other office equipment as necessary. Requires normal range of hearing, eyesight and speech to prepare and communicate appropriate reports and to train staff in system applications.
Applicants should submit resumes to Slarsen@santehealth.net