Credentialing Auditor

Job Title: Credentialing Auditor

Target Compensation Range: $73,000 - $76,000/year, depending on the relevant qualifications and experience.

About Us:

Astiva Health, Inc., located in Orange, CA is a premier healthcare provider specializing in Medicare and HMO services. With a focus on delivering comprehensive care tailored to the needs of our diverse community, we prioritize accessibility, affordability, and quality in all aspects of our services. Join us in our mission to transform healthcare delivery and make a meaningful difference in the lives of our members.

SUMMARY: The Credentialing Auditor is responsible for conducting IPA Due Diligence Pre-Delegation and annual delegation audits, tracking and analyzing IPA quarterly reports and presenting information as required , attending Health Industry Collaboration Effort (ICE) Shared Credentialing Team meetings, and assisting with daily credentialing/re-credentialing activities as deemed necessary. This position requires travel to various locations throughout California to conduct audits, onsite.

Essential Functions and Key Responsibilities:

• Coordinate and conduct pre-delegation and annual Audits/Credentialing IPA due diligence audits, prepare audit reports, and follow-up and respond to IPA s corrective action plan (CAP) for the audits, as applicable.
• Credentialing Audits included within the scope of this position include: IPAs/MSOs, Facilities, HDOs, Dental, Acupuncture, and Other Supplemental Audits, as deemed necessary
• Develop and maintain department policies and procedures.
• Review and process initial credentialing applications. Update and process all recredentialing applications and requests.
• Maintain and update provider data in credentialing database via continuous data maintenance.
• Maintain recredentialing and revalidation statuses for existing providers for government and commercial payors.
• Follow up with providers on submitted applications and to obtain individual provider effective dates when application is approved.
• Review and update the Credentialing audit tool annually to ensure compliance with current NCQA, CMS, DHCS and DMHC requirements.
• Work closely with Delegation Oversight Committee (DOC) and Provider Network Operations to ensure that audits are completed timely.
• Track, follow-up, analyze and report on IPA s and other Supplemental vendor required quarterly credentialing reports to DOC as a member of the DOC Committee, Credentialing Committee, and other committees as designated.
• Collect and record fully executed Credentialing Delegation agreements (as needed).
• Assist Compliance with reports to federal and state agencies, as required.
• Actively participate in the ICE monthly meetings, credentialing activities and updates.
• Prepare and present Credentialing activities and files for oversight audits, state and federal audits, as required.
• Assist with general prepping of credentialing/re-credentialing activities as deemed necessary.
• Utilize, as applicable, the Plan’s contracted Primary Source Verification vendor to submit prepared files. Utilize HICE Shared Credentialing Audits by obtaining authorizations from provider groups.
• Prepare and present files to the Astiva Credentialing Committee as required to meet contracting deadlines.
• Regular and consistent attendance
• Other duties as assigned

EDUCATION and/or EXPERIENCE:

• High School diploma or GED required
• Bachelor’s degree in Healthcare Administration, Finance, Business Administration or related field or a combination of education and experience
• 5 years previous experience in a credentialing role within a health plan, IPA, or medical group strongly desired.
• Strong working knowledge of Medicare, Medicaid and health plan credentialing required.
• Stellar critical thinking with the ability to independently research complex issues and work toward resolution.
• Communicate professionally with internal teams and external providers and groups.
• Strong working knowledge of MS Office including Word, Excel and Outlook
• Valid CA Driver's License and proof of auto insurance coverage

BENEFITS:

• 401(k)
• Dental Insurance
• Health Insurance
• Life Insurance
• Vision Insurance
• Paid Time Off