Credentialing Coordinator​/Req

Brief Description

The Credentialing Coordinator works under the supervision of the Supervisor, Peer Review and Credentialing and assists in all aspects of the Credentialing department functions. The Coordinator is responsible for coordinating, monitoring, and maintaining the credentialing and recredentialing processes of health care providers and practitioners to ensure they meet the requirements of the Alliance credentialing policies and regulatory agencies including, but not limited to, Title 22, NCQA, DHCS, DMHC, and CMS.

Applicants must be a California resident as of their first day of employment.

• Application Maintenance
  • Prepare initial Credentialing application requests for Chief Medical Officer or Medical Director review.
  • Send and track Credentialing application requests.
  • Evaluate Credentialing applications for completeness and compliance.
  • Coordinate initial and recredentialing file processing with Credentialing Verification Organization (CVO).
  • Audit files, obtain credentialing documents or additional information as required.
  • Track and follow up on all credentialing/recredentialing documentation as necessary.
  • Contact practitioners to clarify discrepancies.
  • Ensure Credentialing application timeliness per NCQA requirements.
• Credentialing Database Maintenance
  • Perform data entry and maintain accuracy and integrity of the credentialing database system.
  • Produce credentialing reports as required for Alliance departments, CVO, and special requests.
  • Review expirable reports and notify Supervisor, Peer Review and Credentialing of potential issues.
• Peer Review and Credentialing Committee Maintenance
  • Provide administrative support for Peer Review Committee (PRC) and the Credentialing Committee (CC) meetings.
  • Prepare and send email reminders to committee members to ensure a quorum.
  • Prepare agendas, files, and needed materials.
  • Assemble meeting packets for meetings.
  • Take minutes, complete follow‑up correspondence, and update the credentialing database.
• Credentialing Requirements Maintenance
  • Monitor ongoing state, federal, and licensing agencies to identify potential provider sanctions on a monthly basis.
  • Ensure credentialing compliance standards are met per accrediting and regulatory agencies while developing and maintaining a working knowledge of statutes and laws.
  • Assist Supervisor, Peer Review & Credentialing with delegated or internal credentialing audits, HEDIS, and other projects as assigned.
  • Assist Supervisor, Peer Review & Credentialing in providing credentialing information to other Alliance departments and staff as required.
  • Complete other duties and special projects as assigned.

• Perform research by accessing a variety of sources including computer‑related sources and paper files in order to review information and report details back to a provider or Alliance staff as appropriate.
• Communicate effectively and efficiently internally and externally and serve as a liaison between providers and vendors. Prepare Peer Review Committee and Credentialing Committee meeting minutes, agendas, medical record summaries, and provider audit performance summaries, monthly or as needed.
• Comply with the organization’s Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.

• Constant and close visual work at desk or computer.
• Constant data entry using keyboard and/or mouse.
• Constant sitting and working at desk.
• Frequent use of telephone headset.
• Frequent verbal and written communication with staff and other business associates by telephone, correspondence, or in person.
• Frequent lifting of folders and other objects weighing between 0 and 30 lbs.
• Frequent walking and standing.

Education or Training Equivalent To:

• Bachelor’s degree or equivalent experience.
• NAMSS Certified Provider Credentialing Specialist (CPCS) and/or Certified Professional Medical Staff Management (CPMSM) certification preferred.

Minimum Years of Additional Related

Experience:

• One to three years experience within a health care/managed care environment required.
• Knowledge of commonly used concepts, practices, and…