Job Summary:

With assistance and oversight from senior team members, the Lead Credentialing Specialist will support Credentialing Associates I & II, and Credentialing Clerk to ensure departmental and developmental goals are met in a timely manner. Assists in performing the credentialing and re-credentialing of provider applications in accordance with the departmental policies and procedures, and in compliance with applicable State and Federal laws and regulations. With support from the Credentialing Manager, the incumbent will maintain files/databases, spreadsheets, and prepare audit materials. Corresponds with affiliate health plans and providers. With oversight, the incumbent will develop and revise policies and procedures for approval.

Essential Job Functions:

• Gathers credentials and re-credentialing materials for contracted providers.
• Prepares credentials file for completion and presentation.
• Provides guidance to the rest of the Credentialing staff, coordinates, and monitors the review and analysis of practitioner applications and reapplications, and accompanying documents to confirm applicant’s eligibility.
• Identifies issues that require additional investigation and evaluation, validates discrepancies, and ensures appropriate follow up.
• Responsible for preparation of the CR, UM, QM Committee agenda.
• Coordinates with manager on annual calendar of meetings, notification of meetings, attendance, and ensures the credentialing and re-credentialing files are complete.
• Maintains a well-documented desk procedure manual to include the job tasks, processes and procedures required to ensure the consistent completion of the duties of this position and subordinates in the absence of the incumbent.
• Responds to inquiries from other healthcare organizations.
• Assists with managed care delegated credentialing audits; conducts internal file audits.
• Monitors the initial process for all Medical/Professional staff and delegated providers. Ensure compliance with rules, regulations, policies, procedures, and delegated contracts.
• Performs related duties consistent with the scope and intent of the position.
• Regular attendance.
• Travel as required.

Other Functions:

• Enforces Company policies and safety procedures.
• Regularly updates job knowledge by participating in educational opportunities, reading professional publications, maintaining professional networks, and participating in professional organizations.

Competencies

• Two (2) years of experience in the medical administration industry required
• High Volume Data Entry Experience required.
• One to two years of Credentialing and Medi-Cal experience required.
• IntelliSoft system experience highly desired.
• Excellent communication skills, including both oral and written.
• Excellent active listening and critical thinking skills.
• Ability to solve mid-level problems with minimal supervision.
• Ability to demonstrate professionalism, confidence, and sincerity while quickly and positively engaging providers.
• Ability to multi-task, exercise excellent time management, and meet multiple deadlines.
• Ability to provide and receive constructive job and/or industry related feedback.
• Ability to maintain confidentiality and appropriately share information on a need to know basis.
• Ability to consistently deliver excellent customer service.
• Excellent attention to detail and ability to document information accurately.
• Ability to work in a dynamic, fast-paced team environment and achieve objectives effectively and positively.
• Demonstrate commitment to the organization’s mission.
• Must have mid-level skills in Microsoft software (Word, Excel, and PowerPoint).
• Must have the ability to quickly learn and use new software tools.
• Must have mid-level skills using Outlook e-mail applications.
• Self-motivated with strong organizational, multi-tasking, planning, and follow up skills.
• Ability to work independently as well as in a team environment.
• Ability to present self in a professional manner and represent the Company image.

Education and Licensure

• High School Diploma or GED minimum requirement.
• AA Degree or higher in Health Care Administration or related field preferred.

Travel

• The incumbent may travel up to 5% of the time.

Work Environment

This job operates in a professional office environment. This role routinely uses office equipment such as computers, phones, photocopiers, scanners and filing cabinets.