Credentialing Specialist

Credentialing Specialist

Department: Ops - Credentialing

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Nicole Turner

Compensation: $23.80 - $30.55 / hour

This position is responsible for performing credentialing and recredentialing activities in accordance with Astrana Health’s Credentialing Policies, contracted health plan requirements, CMS regulations, applicable state laws, and NCQA accreditation standards.

• Review practitioner and organizational provider credentialing and recredentialing applications for completeness
• Review and analyze credentialing documents, including education, residency and fellowship training, board certification and eligibility, licensure, professional work history, liability insurance, requests for clinical privileges, malpractice history, and accreditation
• Assess completeness of information and provider’s qualifications relative to established standards
• Determine appropriate verification and reference letters to be prepared for adequate processing of each individual application and reapplication
• Identify and flag adverse information from provider application materials for the purpose of conducting follow-up investigations
• Request facility site reviews from appropriate source (i.e. Cal Optima, Health Net, IEHP, etc) on applicable providers
• Responsible for completion of recredentialing files within 36-month timeframe
• Update new information as received via recredentialing process
• Maintain and exceed quantity and quality goals and standards set by the department

Requirement:

• High school diploma or equivalent
• 1-2 years of experience in credentialing, provider enrollment, contracting or similar field.

You're great for the role if:

• Licensure, Certification, Registration: CPCS or CPMSM certification
• 2-3 years’ credentialing experience within a managed care, hospital or CVO credentialing