Location: Orange, California US
Job Number: 1590
Position Title: Credentialing Specialist
The Credentialing Specialist is responsible for all aspects of credentialing and re-credentialing for providers, including physicians and healthcare delivery organizations as required. This position is responsible for preparing and maintaining reports of credentialing activities such as licensure, accreditation, membership or facility privileges. The Credentialing Specialist is responsible for ensuring that 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
(May include but are not limited to)
- Communicates by phone and in writing with provider offices regarding the application process.
- Accesses 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.
- Maintain accurate demographic & credentialing information in database
- Communicate with Credentialing Verification Organization as needed
- Process NPDB, OIG, EPLS and Medicare Opt-Out
- Ensure application complies with NCQA requirements
- Prepare provider and HDO credentialing and re-credentialing files for committee review
- Assist with processing Committee review results including Minutes, system updates, notification letters to providers and internal staff
- Performs re-credentialing process every three (3) years of active providers within the network.
- Identify providers that are due for re-credentialing
- 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.
- Maintains 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
- Perform other duties, as required or assigned
- 1-3 years’ experience in the field of credentialing in a healthcare environment
- High School Diploma or equivalent, some college a plus
- CPCS Credentialing Certificate a plus or willingness to obtain when eligible
- Excellent written and verbal communication skills
- Extremely detail oriented
- Proven follow-up skills
- Proficient in Microsoft Office, knowledge of other systems preferred
- Knowledge of Medicare Application processing
Essential Physical Functions:
The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.
- While performing the duties of this job, the employee is regularly required to talk or hear.
- The employee regularly is required to stand, walk, sit, use hand to finger, handle or feel objects, tools, or controls; and reach with hands and arms.
- The employee frequently lifts and/or moves up to 10 pounds.
- Specific vision abilities required by this job include close vision and the ability to adjust focus.
Location City: Orange
Location State: California
Community / Marketing Title: Credentialing Specialist
Who is Alignment Healthcare?
- Socially responsible
- Technologically enabled
- Concierge care
- Servant leadership
We are dedicated to transforming the complex and confusing process of medical treatment in the United States so that every link in the health care continuum becomes more efficient, productive, and effective. We built a team of people who want to make a difference. Come join the team that is changing health care one person at a time.
We believe that great work comes from people who are inspired to be their best. We invite you to explore our wide variety of roles based on your unique experience.
EEO Employer Verbiage:
Alignment Healthcare, LLC is proud to practice Equal Employment Opportunity and Affirmative Action. We are looking for diversity in qualified candidates for employment: Minority/Female/Disable/Protected Veteran.
If you require any reasonable accommodation under the Americans with Disabilities Act (ADA) in completing the online application, interviewing, completing any pre-employment testing or otherwise participating in the employee selection process, please contact email@example.com.