Credentialing Specialist

SUMMARY

The Credentialing Specialist position has primary responsibility for processing paperwork relating to credentialing and recredentialing ensuring databases detailing the practitioners' education, training, licensing, experience and other information are up to date.

Evaluate and process credentialing for appointment of practitioners and follow credentialing standards of National Commission of Quality Assurance (NCQA) and The Joint Commission Standards, managed care requirements.

ESSENTIAL FUNCTIONS

Receives and processes applications for credentialing and privileging from licensed independent practitioners and allied health professionals applying for membership in the Professional Staff Association (PSA);

notifies the respective department chair and the applicant of their status and time frames for completion.

• Reviews applications for required documentation; verifies credentials, education, employment history, licensure, professional references, hospital affiliations and liability claims history by performing on-line queries from a variety of resources, such as the National Practitioner Data Bank, American Medical Association, Drug Enforcement Administration, and Office of the Inspector General.
• Ensures physicians, allied health professionals and other practitioners of a healthcare facility are properly licensed, trained, and certified as mandated by state and federal regulations.
• Reviews requested privileges to ensure that appropriate criteria and training is documented for the privileges sought.
• Monitors documentation of provisional applications for completion of proctoring; notifies the respective department chair and provisional members regarding their status and time frames for completion of proctoring.
• Prepares summary report of each application for evaluation and review by the Credentials and Medical Executive Committees;

identifies any potential adverse information.

Maintains application and credentialing files in a confidential manner; regularly enters credentialing information into the database to ensure information on credentialing, privileging, certifications, prerogatives and competencies are current;

disseminates data to authorized personnel.

Prepares reports or credential files for periodic audits by Consolidated Accreditation and Licensure Survey and Office of Managed Care as requested;

conducts internal reviews; and completes required tasks as necessary.

Generates letters to hospital affiliations and other agencies to obtain information of the practitioner's professional competency.

Responds to inquiries from other agencies requesting employment verification and relevant information on current and past members of the PSA.

• Prepares reports for various committees as requested on a periodic basis.
• Participates in the development and implementation of credentialing processes and procedures.

JOB QUALIFICATIONS

• Ability to follow policies and procedures, established by departmental by-laws and regulatory agencies, to evaluate and verify professional licensure, education, training, experience, competencies, and hospital affiliations to ensure that medical providers are appropriately qualified and privileged.
• Ability to follow oral and written instructions.
• Ability to exercise sound judgment while working in a stressful environment.
• Ability to bend, pull, push, and lift up to 40 pounds.

Education / Experience

Two years of recent, full-time, paid experience in a Medical Staff Services office at the level of the Los Angeles County class of Intermediate Typist Clerk or higher - OR - Certification as a Certified Provider Credentialing Specialist issued by the National Association of Medical Staff Services.

Certificates / Licenses / Clearances

• A valid California Class C Driver License or the ability to utilize an alternative method of transportation when needed to carry out job-related essential functions.
• Successfully clear the LA County Live Scan process.
• Successfully clear the Health Clearance
• Must comply with LA County Health Officer COVID-19 vaccine order. Must be Fully Vaccinated.

PHYSICAL DEMANDS

Stand : Frequently

Walk : Frequently

Sit : Frequently

Handling : Occasionally

Reach Outward : Occasionally

Reach Above Shoulder : Occasionally

Climb, Crawl, Kneel, Bend : Occasionally

Lift / Carry : Occasionally - Up to 50 lbs

Push / Pull : Occasionally - Up to 50 lbs

See : Constantly

Taste / Smell : Not Applicable

Not Applicable Not required for essential functions

Occasionally (0 - 2 hrs / day)

Frequently (2 - 5 hrs / day)

Constantly (5+ hrs / day)

WORK ENVIRONMENT

General Office Setting, Indoors Temperature Controlled, Indoor Setting

EEOC STATEMENT

It is the policy of Heluna Health to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information or any other protected characteristic under applicable law.