Credentialing Data Specialist


Community Health Group is a locally based non-profit health plan that ensures access to high quality, culturally sensitive health care for underserved communities throughout San Diego County. We treat our 300-member, multi-lingual staff like family, encouraging an atmosphere of collaborative teamwork, continuous learning, personal growth, and promotion from within. Recognized as one of the Top Workplaces in San Diego, CHG offers its employees such benefits as tuition reimbursement, a meditation room and yoga classes, a monthly Breakfast With The CEO, and memorable events throughout the year. 

We know that by serving our employees well, they, in turn, will better serve our nearly 300,000+ membership. We have been recognized consistently for the excellence and sensitivity of our customer service by members, physicians, vendors, and a full range of health care providers. We are accredited by the National Committee for Quality Assurance and proud of our continuing company-wide Quality Initiatives.

We are currently recruiting for:

Credentialing Data Specialist

 

POSITION SUMMARY

Ensures company maintains high standards of provider credentialing and compliance to regulatory requirements by performing administrative credential support and ensuring accurate and timely computer entry of data.

 

COMPLIANCE WITH REGULATIONS

Works closely with all departments necessary to ensure that the processes, programs and services are accomplished in a timely and efficient manner in accordance with CHG policies and procedures and in compliance with applicable state and federal regulations including CMS and/or Medicare Part D, DHCS and DMHC.

 

RESPONSIBILITIES

  • Maintains a current, accurate provider database by performing practitioner credentialing data entry, maintaining the integrity of the credentialing computerized data base and hard copy files; complying with policies and procedures for the credentialing work process in accordance to federal, state, the National Committee for Quality Assurance (NCQA), and company guidelines with 98% accuracy.

  • Complies with federal, state and local requirements             by studying existing requirements, adhering to requirements, and advising management on needed actions.

  • Oversight & management of Credentialing & Re-credentialing with 98% data accuracy by requesting application packets as needed, performing primary verifications for NPDB, licensure and regulatory sanctions, preparing files for final review, timely follow up via tickler system, quality review, and final file audits.  Responsible for primary & delegated credentialing oversight with IPAs & medical groups as assigned.  Responsible for ongoing monitoring of licensing boards and sanctions. 

  • Database management with 98% data accuracy by reviewing & entering practitioner adds, changes, terminations, and scanning documents necessary to maintain an accurate database, including Non-Physician Medical Practitioner (NPMP) & Hospital Based Physicians (HBP).  Responsible for updating expired credentials (License, DEA, Liability, Board Certification and Accreditation.  Responsible for data accuracy validation via calls & faxes to provider’s offices and roster comparison.

  • Contributes to department's effectiveness by identifying potential or actual utilization/quality management issues that must be addressed, providing information and commentary pertinent to decision making; meeting with the Credentialing Manager to review operational issues, as required.

  • Prepares reports by executing computerized credentialing reports and written documentation as required by the credentialing process as directed.

  • Maintains inter- and intra-departmental work flow by establishing and maintaining effective communications with internal and external contacts.

  • Keeps supervisor informed of activities by preparing and submitting a monthly productivity report as needed.

  • Maintains professional and technical knowledge by attending educational workshops, reviewing professional publications, establishing personal networks, and participating in professional organizations.

  • Maintains customer confidence and protects company operations by keeping information confidential.

  • Contributes to the team effort by accomplishing related duties as assigned or requested.

  • Maintains product and company reputation and contributes to the team effort by conveying professional image and accomplishing related tasks; participating on committees and in meetings; performing other duties as assigned or requested.

 

EDUCATION

  • Post high school vocational/specialized training or equivalent formal education in data entry.

  • Certified Provider Credentialing Specialist (CPCS) preferred.

     

    EXPERIENCE/ SKILLS              

  • 1 year clerical position.

  • Working knowledge of credentialing database, ACCESS.

  • Credentialing or medical staff office experience preferred.

  • Vistar credentialing software experience preferred.

  • Intermediate working knowledge of Microsoft programs (Word, Excel, Outlook, etc.). .

  • Strong organizational skills; ability to maintain orderly files and records.

  • Excellent written and oral communication skills.

  • Ability to interface effectively with internal staff and provider populations.

  • Ability to work independently and meet deadlines.

  • Bilingual (English/Spanish) preferred.

     

    PHYSICAL REQUIREMENTS

  • Prolonged (up to 100%) sitting and data entry.

  • Lifting (up to 10 lb.).

  • May be required to work evenings and/or weekends.