Credentialing Specialist

Job Number: 1386

Workplace Type:

Position Title: Credentialing Specialist

External Description:

Position Summary:

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.

 

General Duties/Responsibilities:

(May include but are not limited to)

 

• Entry of provider information into the systems
• Send out application receipt letter to providers
• Process outgoing and incoming primary source verifications
• Process NPDB, OIG, EPLS and Medicare Opt-Out
• Ensure application complies with NCQA requirements
• Assists with coordinating 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.
• Submit new providers to contracted health plans
• Notify IPA’s/Health Plans of provider changes and terminations
• Check provider status
• Responsible for data accuracy in EZCap and Provider Network application for credentialed contracted providers.
• Responsible in updating credentialing provider roster database.
• 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

 

Supervisory Responsibilities:

 

N/A

 

Minimum Requirements:

 

1. 1-3 years’ experience in the field of credentialing in a healthcare environment

 

1. Education/Licensure:
   1. High School Diploma or equivalent, some college a plus
   2. Credentialing Certificate a plus
2. Other:
   1. Excellent written and verbal communication skills
   2. Extremely detail oriented
   3. Proven follow-up skills
   4. Proficient in Microsoft Office, knowledge of other systems preferred

1. 1. 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.

 

1. While performing the duties of this job, the employee is regularly required to talk or hear.
2. 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.
3. The employee frequently lifts and/or moves up to 10 pounds.
4. Specific vision abilities required by this job include close vision and the ability to adjust focus.

 FLSA Status: Non-Exempt

 

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.

City: Orange

State: California

Location City: Orange

Location State: California

Community / Marketing Title: Credentialing Specialist

Company Profile:

By leveraging our world-class technology platform, innovative care delivery models, deep physician partnerships and our serving heart culture, Alignment Health is revolutionizing health care for seniors! From member experience professionals and clinicians, to data scientists and operations leaders, we have built a talented and passionate team that is deeply committed to our mission of transforming health care for the seniors we serve. Ready to join us?

At Alignment, delivering exceptional care to seniors starts with ensuring an exceptional experience for our over 1,300 employees. At the center of our employee experience is a culture where employees at all levels and across all teams are encouraged to share their unique ideas and perspectives. After all, when you can bring your authentic self to work, whether that’s in a clinical setting, our corporate office or a home office, creativity and innovation flourish! Another important part of the Alignment culture is a belief in continuous learning and growth. As a result, in this fast-growing company, you will find ample support to grow your skills and your career – with us.

EEO Employer Verbiage:

 

Please note: All clinical positions are contingent upon successful engagement with Alignment Health’s COVID-19 Vaccination program (fully vaccinated with documented proof or approved exception/deferral).

Alignment Health is an Equal Opportunity/Affirmative Action Employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, national origin, disability, age, protected veteran status, gender identity, or sexual orientation.

*DISCLAIMER: Please beware of recruitment phishing scams affecting Alignment Health and other employers where individuals receive fraudulent employment-related offers in exchange for money or other sensitive personal information. Please be advised that Alignment Health and its subsidiaries will never ask you for a credit card, send you a check, or ask you for any type of payment as part of consideration for employment with our company. If you feel that you have been the victim of a scam such as this, please report the incident to the Federal Trade Commission at https://reportfraud.ftc.gov/#/. If you would like to verify the legitimacy of an email sent by or on behalf of Alignment Health’s talent acquisition team, please email [email protected].