The expected pay range is based on many factors such as geography, experience, education, and the market. The range is subject to change.
What You Will Be Doing:
Under general supervision, the Credentialing Specialist Lead coordinates the daily operations of the Credentialing unit and conducts credentialing activities consistent with HPSJ guidelines and contractual and regulatory standards. Work is occasionally varied and minimally to moderately complex, and requires a limited to moderate degree of discretion and independent judgment.
Our Vision:
Continuously improve the health of our community.
Our Mission:
We provide healthcare value and advance wellness through community partnerships.
Essential Functions:
- Monitors credentialing activities on a daily and weekly basis to ensure compliance with HPSJ and regulatory and contractual standards; resolves routine workload and other issues; makes recommendations on more complex issues.
- Collaborates with interdepartmental units to establish and improve workflow and processes: identifies issues and opportunities; resolves issues or makes recommendations as required.
- Sets up and maintains data collection and reporting systems; inputs data as required; produces routine and AdHoc reports.
- Implements and maintains credentialing department guidelines, policies and procedures and communicates changes to appropriate individuals in a timely and effective manner; makes recommendations for revisions.
- Resolves or facilitates resolution of the most complex credentialing issues.
- Assists with the revisions and enhancements of CACTUS software and other tools.
- Identifies training needs and opportunities; assists in developing and delivering routine and ad hoc department training.
- Prepares for and participates in regulatory audits; gathers information, maintains required reports, develops and monitors timely and effective corrective actions plans.
- Assists the Quality Improvement Department with facility site reviews (FSRs) and maintains FSR aggregate.
- Reviews and verifies credentialing and recredentialing documentation for accuracy, and compliance with HPSJ policies and other mandated standards
- Conducts and obtains credentialing verifications submits completed profiles to Medical Director for review; prepares for submission to Peer Review/Credentialing Committee.
- Coordinates the Peer Review/Credentialing Committee meeting by preparing agendas, compiling, assembling and distributing packets, reviewing minutes for accuracy. Follows-up on Action Items generated by the committee members at the Peer Review/Credentialing Committee Meeting.
- Notifies providers of outcomes of credentialing process; notifies appropriate internal and external stakeholders of provider status changes according to established internal timelines.
What You Bring:
Knowledge, Skills, Abilities and Competencies
Required
- Produces work that is accurate and complete.
- Produces the appropriate amount of work.
- Actively learns through experimentation when tackling new problems, using both successes and failures to learn.
- Rebounds from setbacks and adversity when facing difficult situations.
- Knows the most effective and efficient process to get things done, with a focus on continuous improvement.
- Strong knowledge of NCQA, DHCS, DMHC, Centers for Medicare and Medicaid Services (CMS) credentialing standards and principles of managed care.
- Strong knowledge of credentialing software systems.
- Strong knowledge of record keeping principles and techniques.
- Strong knowledge of practitioner verification requirements and data base systems.
- Strong knowledge of audit processes, and the ability to effectively implement and maintain them.
- Ability to read, interpret and apply complex written guidelines, instructions and other materials.
- Strong planning and organizational skills with the ability to effectively prioritize multiple tasks.
- Interpersonal skills - interacts effectively with individuals both inside and outside of HPSJ; relates openly and comfortably with diverse groups of people.
- Strong oral and written communications skills with the ability to communicate persuasively to diverse individuals inside and outside of HPSJ.
- Time management and organizational skills. Uses time effectively and efficiently. Values time. Concentrates his/her efforts on the more important priorities. Can attend to a broader range of activities. Meets deadlines.
- Good presentation skills.
- Ability to use tact and diplomacy to diffuse emotional situations.
- Strong facilitation, problem solving and conflict resolution skills, with the ability to use tact and diplomacy to diffuse emotional situations.
- Ability to commit to and facilitate an atmosphere of collaboration and team work.
- Ability to gather and compile data and information, and perform simple analysis.
- Ability to work independently and as part of a team.
- Ability to speak and be understood in English.
- Type 50 WPM at 90%.
- Strong customer service skills.
- Ability to assist developing and delivering relevant and effective training and supporting materials.
- Intermediate skills in Word and Excel, including the ability to create formulas and pivot tables.
- Basic mathematics skills.
- Ability to speak and be understood in English.
- Commitment and demonstrated ability to act as a role model for HPSJ’s vision, mission and values.
- Ability to handle confidential information with appropriate discretion.
What You Have:
Education and Experience
Required
- HS Diploma or equivalent.
- At least three years as a Credentialing Specialist.
Preferred
- Experience working with Medi-Cal and/or Medicare, or other state or federally sponsored programs.
- Experience working in a Medical managed care setting.
Licenses, Certifications
Required
- Valid California driver license and reliable transportation or, the ability to obtain transportation on demand in the counties served by HPSJ if prohibited from getting a driver license due to a medically documented disability.
What You Will Get:
HPSJ Perks:
- Competitive salary
- Robust and affordable health/dental/vision with choices in providers
- Generous paid time off (accrue up to 3 weeks of PTO, 4 paid floating holidays including employee’s birthday, and 9 paid holidays)
- CalPERS retirement pension program, automatic employer-paid retirements contributions, in addition to voluntary defined contribution plan
- Two flexible spending accounts (FSAs)
- Employer-Paid Term Life and AD&D Insurance
- Employer-Paid Disability Insurance
- Employer-Paid Life Assistance Program
- Health Advocacy
- Supplemental medical, legal, identity theft protection
- Access to exclusive discount mall
- Education and training reimbursement in addition to employer-paid elective learning courses.
- A chance to work for an organization that is mission-driven – our members and community are at the core of everything we do.
- A shorter commute – if you’re commuting from the Central Valley to the Bay Area.
- Visibility and variety – you have a chance to work with people at all levels of the organization, and work on diverse projects.
We are an equal opportunity employer and diversity is one of our core values. We believe that differences including race, ethnicity, gender, sexual orientation, and other characteristics, will help us create a strong organization that is sensitive to the needs of those we serve. Employment decisions are made on the basis of qualifications and merit.
HPSJ provides equal employment opportunities to employees and applicants for employment and prohibits discrimination based on color, race, gender (including gender identity and gender expression), religion (including religious dress and grooming practices), marital status, registered domestic partner status, age, national origin (including language use) or ancestry, physical or mental disability, medical condition (including cancer and genetic characteristics), sex (including pregnancy, childbirth, breastfeeding or related medical condition), genetic information, sexual orientation, military or veteran status, political affiliation or any other characteristic made unlawful by applicable Federal, State or local laws. It also prohibits unlawful discrimination based on the perception that anyone has these characteristics or is associated with anyone who has or is perceived to have these characteristics.
Important Notice: This job description is not a contract between HPSJ and the employee performing the job. The duties listed in the job description may be changed at the discretion of HPSJ, and HPSJ may request the employee to perform duties that are not listed on the job description.
Equal employment opportunity, including veterans and individuals with disabilities.
