Credentialing Coordinator

  • CalOptima
  • 505 City Pkwy W, Orange, California
  • Aug 02, 2022
Full Time Human and Social Services Public Health

Job Description


Credentialing Coordinator

Job Description
Why CalOptima?
CalOptima is the single largest health plan in Orange County, serving 880,000 members, or one in four residents. Our motto — "Better. Together.” — is at the heart of our mission to serve members with excellence, dignity and respect. We are a public agency made up of compassionate leaders and professionals working together to strengthen our community's health. If you're looking for an opportunity to work for an organization dedicated to improving local health care and serving the needs of the most vulnerable, we encourage you to join CalOptima.

Job Summary

The Credentialing Coordinator performs verification and processing of moderately complex to advanced level documents and database information. The incumbent uses standard policies, procedures, and guidelines for the coordination, monitoring, and processing of credentialing and re-credentialing of Behavioral Health practitioners, providers, mid-levels, Applied Behavioral Analysts (ABA) and Board Certified Behavioral Analysts (BCBA), allied health professionals and other Organizational Providers (OP) based on regulatory, accreditation, contractual and CalOptima standards.

Position Responsibilities:
  • Participates in a mission driven culture of high-quality performance, with a member focus on customer service, consistency, dignity and accountability.
  • Assists the team in carrying out department responsibilities and collaborates with others to support short and long-term goals/priorities for the department.
  • Ensures that the required timely documentation is appropriate and complete for verification processing, that includes but is not limited to the following providers: Behavioral Health practitioners, ABAs, BCBAs, mid-levels, allied health professionals, and other health care delivery organizations for the credentialing and re-credentialing process.
  • Processes all credential applications, initials and re-credentials and/or applications in established electronic file folders.
  • Conducts other follow-up as required into the applicant's background, education and experience using online systems, written correspondence, telephone inquiries, printed reference guides and reports.
  • Performs and collects primary source verification (PSV) documentation for licensing, board certifications, proof of required insurance, National Practitioner Data Bank (NPDB) and/or other sources as required based on National Committee for Quality Assurance (NCQA) standards, and CalOptima requirements and policies.
  • Partners with all necessary staff to ensure an integrated, timely and consistent product.
  • Collaborates with the Provider Relations and Contracting department on the status of candidates to ensure timely credentialing.
  • Monitors and maintains reports published by the Medical Board of California (MBOC), Centers for Medicare and Medicaid Services (CMS), Department of Health Care Services (DHCS), Office of Inspector General (OIG), National Practitioner Data Bank (NPDB) and other applicable sources to identify adverse findings.
  • Prepares reports as requested.
  • Implements an efficient and effective system for the transmission of credential information to internal and external sources to facilitate timely approval to participate as a CalOptima approved practitioner, provider or OP.
  • Provides consistent and timely follow-up on all outstanding credentialing and re-credentialing files.
  • Maintains the credentialing database and ensures up-to-date information is always obtained.
  • Stays aware of changes and updates in laws and regulatory requirements.
  • Writes, revises and implements desktop procedures as necessary to remain in compliance and create efficiency.
  • Documents the monitoring of adverse license actions and legal actions.
  • Cross-trains within department to support credentialing operations to provide back-up support for credentialing files during department absences such as vacation or paid time off.
  • Completes other projects and duties as assigned.

Possesses the Ability To:
  • Function independently with minimal direct supervision and be detail oriented.
  • Communicate clearly and concisely, both verbally and in writing.
  • Establish and maintain effective working relationships with CalOptima leadership and staff, as well as contracted committee members and practitioners with sensitive issues.
  • Organize credentialing processes and understand and apply credentialing criteria consistently across CalOptima Direct, health networks, and physician medical groups.
  • Maintain confidentiality of peer review information.
  • Utilize computer and appropriate software (e.g., Microsoft Office: Word, Outlook, Excel, PowerPoint) and job specific applications/systems to produce correspondence, charts, spreadsheets and/or other information applicable to the position assignment.

Experience and Education:
  • High school diploma or equivalent required.
  • 2 years of experience with credentialing in a hospital or ambulatory setting, such as health plan, medical group, or Independent Physician Association (IPA) required.

Preferred Qualifications:
  • Bachelor's degree in Health Care Administration or related field preferred.
  • Certification as Certified Provider Credentialing Specialist (CPCS) preferred.

Knowledge of:
  • Medical Terminology.
  • Credentialing standards, requirements, processes and procedures
  • Federal and State regulatory requirements and accreditation standards: NCQA, The Joint Commission, DHCS, DMHC, CMS, and other relevant or accreditation certifying agencies.

Department(s): Quality Improvement
Reports to: Supervisor, Quality Improvement
FLSA status: Non-Exempt
Salary Grade: E - $23.08 - $32.79 ($48,000 - $68,200)

CalOptima is an equal employment opportunity employer and makes all employment decisions on the basis of merit. CalOptima wants to have qualified employees in every job position. CalOptima prohibits unlawful discrimination against any employee, or applicant for employment, based on race, religion/religious creed, color, national origin, ancestry, mental or physical disability, medical condition, genetic information, marital status, sex, sex stereotype, gender, gender identity, gender expression, transitioning status, age, sexual orientation, immigration status, military status as a disabled veteran, or veteran of the Vietnam era, or any other consideration made unlawful by federal, state, or local laws. CalOptima also prohibits unlawful discrimination based on the perception that anyone has any of those characteristics or is associated with a person who has, or is perceived as having, any of those characteristics.

If you are a qualified individual with a disability or a disabled veteran, you may request a reasonable accommodation if you are unable or limited in your ability to access job openings or apply for a job on this site as a result of your disability. You can request reasonable accommodations by contacting Human Resources Disability Management at 657-900-1134.

Job Location: Orange, California
Position Type:

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Job Address

505 City Pkwy W, Orange, California 92868 United States View Map