PRINCIPLE RESPONSIBILITIES: Under the general guidance of the Senior Manager, Peer Review and Credentialing (PRCC), the Credentialing Quality Assurance Specialist is responsible for auditing the quality of work performed by Credentialing staff to ensure they meet the requirements of Alameda Alliance for Health's (Alliance) regulatory agencies and/or guidelines (i.e., California Code of Regulations Title 22, NCQA, DHCS, DMHC, and CMS) and the Alliance's credentialing policies and procedures.
Principle responsibilities include:
Audits
Create and maintain audit reports to monitor credentialing database accuracy.
Perform provider file audits to ensure that credentialing procedures meet regulatory requirements and Alliance standards, and that credentialing files are complete.
Perform credentialing data system audit of initial and re-credentialing files for accuracy and integrity of the credentialing database system.
Work with the Senior Manager, PRCC to perform annual Delegated audits and maintain reports.
Work with the Senior Manager, PRCC to perform Quarterly audits and maintain reports.
Complete annual audit of the credentialing database as specified by the National Committee for Quality Assurance (NCQA).
Update and maintain license monitoring reports that are received from our Credentials Verification Organization (CVO) and managed within the credentialing database.
Send and track initial and re-credentialing application requests.
Processing initial and re-credentialing application requests as needed.
Evaluate applications for completeness.
Track and follow up on all credentialing and re-credentialing documentation, as necessary.
Work with the CVO to track applications for status and ensure they are completed within the credentialing timeframes.
Maintain provider files to ensure that the correct provider file is saved in the appropriate folder, following each Peer Review Committee (PRC) meeting and Credentialing Committee (CC) Meeting.
Work with the Senior Manager, PRCC and team before each PRC and CC meeting to validate that all credentialing and re-credentialing files for the specific month are listed in the credentialing committee packet.
Peer Review Committee and Credentialing Committee Support
Provide administrative support for PRC and CC meetings.
Prepare and send email reminders to members to ensure a quorum.
Prepare agendas, files, and needed materials.
Assemble meeting packets and/or prepare for web-based meetings.
Plan and schedule meeting space and order catering for meetings, if applicable.
Take minutes, complete follow-up correspondence, and update the credentialing database.
ESSENTIAL FUNCTIONS OF THE JOB: Ability to access and research a variety of sources including computer-related sources and paper files to review information in files/computer 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, vendors, and health plan members.
Maintain provider files.
Comply with the organization's Code of Conduct, all regulatory and contractual requirements, organizational policies, procedures, and internal controls.
Other duties as assigned.
PHYSICAL REQUIREMENTS: Constant and close visual work at desk or computer.
Constant data entry using keyboard and/or mouse.
Constant sitting and working at a 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.
Number of Employees Direct Supervision: 0
Number of Employees In-Direct Supervision:0
MINIMUM QUALIFICATIONS: EDUCATION OR TRAINING EQUIVALENT TO: Bachelor's degree in a health-related discipline or equivalent experience National Association Medical Staff Services (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 of experience within a health care/managed care environment required.
Knowledge of commonly used concepts, practices, and procedures used in health care credentialing.
Minimum two years previous credentialing experience preferred.
SPECIAL QUALIFICATIONS (SKILLS, ABILITIES, LICENSE): Working knowledge of Medical Staff principles and operations specific to regulatory expectations.
Sound knowledge and understanding of the Credentialing Committee and peer review process.
Experience with Symplr Provider Software or similar credentialing system.
Possess excellent interpersonal, writing, and communication skills.
Possess excellent organizational skills and attention to detail.
Able to maintain strict adherence to deadlines.
Able to meet productivity and quality goals.
Able to build successful internal and external customer relations.
Able to function well within a team environment and independently.
Able to maintain confidentiality.
Proficient experience in use of various computer system software including Windows, Microsoft Word, MS Project, Excel, Access, Outlook, Visio, and PowerPoint.
SALARY RANGE $69,606.86 - $104,410.30 ANNUALLY The Alliance is an equal opportunity employer and makes employment decisions on the basis of qualifications and merit.
We strive to have the best qualified person in every job.
Our policy prohibits unlawful discrimination based on race, color, creed, gender, religion, veteran status, marital status, registered domestic partner status, age, national origin or ancestry, physical or mental disability, medical condition, genetic characteristic, sexual orientation, gender identity or expression, or any other consideration made unlawful by federal, state, or local laws.
M/F/Vets/Disabled.