Credentialing Specialist I

Position Summary/Position

Under the direction of the Credentialing Supervisor, the Credentialing Specialist is responsible to coordinate all credentialing activities, to ensure that all IEHP contracted Providers and delegated Providers meet credentialing requirements according to NCQA, state and federal regulatory guidelines. 

Major Functions (Duties and Responsibilities)

1. Responsible for maintaining knowledge of IEHP credentialing policies and procedures, NCQA Standards and regulations by CMS, DHCS and DMHC in relation to credentialing requirements and compliance.
2. Responsible for the gathering and researching of credentialing information for the entire IEHP provider network.
3. Responsible for understanding the relationships between IEHP and IEHP Direct, as well as the IEHP delegation of Provider credentialing responsibilities.
4. Conduct thorough background investigation, research, and primary source verification of all components of the application file.
5. Identify issues that require additional investigation and evaluation, validate discrepancies, and ensure appropriate follow up.
6. Prepare credentialing documents for review and approval by IEHP Medical Director and Credentialing Subcommittee.
7. Interface with internal and external customers on day-to-day credentialing and help troubleshoot issues as they arise.
8. Responsible for establishing effective and collaborative working relationships with all Team Members involved in onboarding Providers, including Team Members who are responsible for reviewing sites, assisting with committee’s preparation, contracting and network maintenance.
9. Coordinate, schedule and attend Peer Review Subcommittee and Credentialing Committee meetings; prepare documents for oversight and action on credentialing, recredentialing, discipline or other actions; prepares and mails correspondence to Providers on the outcome of meetings.
10. Assist in preparing for audits by IEHP regulatory bodies.
11. Timely completion of credentialing packets, which include timely and accurately entering of approved providers into the IEHP database and updates of designated providers.
12. Responsible for maintaining the integrity of the IEHP Provider data and ensure that the data available for IEHP Members, Providers and IEHP Team Members is accurate. This includes working on QA/Error Report daily to immediately make any necessary data corrections.
13. Preparing documentation for review by the Credentialing & Peer Review Subcommittees.
14. Process and monitor the initial and recredentialing process for all credentialed Providers, and delegated providers, ensuring compliance with regulatory bodies, as well as Medical Staff Bylaws, Rules and Regulations, policies and procedures, and delegated Providers.
15. Track license and certification expirations for all providers to ensure timely renewals.
16. Issue correspondence relating to Credentialing & Peer Review Subcommittee decisions.
17. Assist in review of the IEHP Provider Manual policies and procedures.
18. Respond to IEHP Provider questions related to credentialing process and credentialing status.
19. Complete Spanish Audit and Provider Directory faxes, calls, and updates.
20. Monitor and update physician status changes as appropriate.
21. Responsible for making updates received through the provider directory process, into the Network Database System.
22. Assist in the review of HIV/AIDS Specialist survey, conducted on an annual basis.
23. Monitor delegated IPA monthly submission of credentialing and recredentialed Providers.
24. Monitor actions against participating physicians and perform appropriate reporting to State, Federal and regulatory entities.
25. Support LEAN activities by actively participating in LEAN initiatives, RIEs, huddles, etc.

Major Functions (Duties and Responsibilities) Cont

Supervisory Responsibilities

Experience Qualifications

One (1) year of experience in an office environment, specifically with credentialing applications and experience in a managed care environment.

Preferred Experience

Education Qualifications

High school diploma or GED required.

Preferred Education

Professional Certification

Professional Licenses

Drivers License Required

Knowledge Requirement

Knowledge of NCQA, state and federal regulatory standards and requirements preferred. 

Skills Requirement

Proficient in Microsoft applications (Microsoft Word, Excel, and extensive knowledge in Access). Excellent written/verbal communication, interpersonal skills, and strong organizational skills, Strong skills in planning, organizing, and meeting deadlines. 

Abilities Requirement

Detail oriented. Ability to establish and maintain effective working relationships with all levels of staff, other programs, agencies, and the general public. Ability to use independent judgment to identify and manage confidential Provider information. Ability to make administrative/procedural decisions and judgments based on regulatory, policy and NCQA standards.

Commitment to Team Culture

The IEHP Team environment requires a Team Member to participate in the IEHP Team Culture. A Team Member demonstrates support of the Culture by developing professional and effective working relationships that include elements of respect and cooperation with Team Members, Members and associates outside of our organization.

Working Conditions

May be required to work away from the primary office 35% of the time or more.  

Work Model Location

Physical Requirements