Accreditation Standards, Analysis Skills, Certified Professional Medical Services Management (CPMSM), Certified Provider Credentialing Specialist (CPCS), Compensation Management, Content Management Systems (CMS), Contract Requirements, Environmental Work, Fellowship, Health Plan, High School Diploma, Hospital Administration, Liability Insurance, Managed Care, National Committee for Quality Assurance (NCQA), Provider Contracting, Provider Credentialing, State Laws and Regulations
Monterey Park, California
Description
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.
What You'll Do
- 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. CalOptima, HealthNet, 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
Qualifications
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
Environmental Job Requirements and Working Conditions
- Our organization follows a hybrid work structure where the expectation is to work both in office and at home on a weekly basis. The office is located at 1600 Corporate Center Dr. Monterey Park, CA 91754.
- The target pay range for this role is between $23.00 - $30.00 per hour. This salary range represents our national target range for this role. Actual compensation will be determined based on geographic location (current or future), experience, and other job-related factors.
Astrana Health is proud to be an Equal Employment Opportunity and Affirmative Action employer. We do not discriminate based on race, religion, color, national origin, gender (including pregnancy, childbirth, or related medical conditions), sexual orientation, gender identity, gender expression, age, status as a protected veteran, status as an individual with a disability, or other applicable legally protected characteristics. All employment is decided based on qualifications, merit, and business need. If you require assistance in applying for open positions due to a disability, please email us at
humanresourcesdept@astranahealth.com
to request an accommodation.
Additional Information:The job description does not constitute an employment agreement between the employer and employee and is subject to change by the employer as the needs of the employer and requirements of the job change.