Provider Credentialing Specialist

Provider Credentialing Specialist

Los Angeles, CA

Compensation: $53,000 to $60,000 per year

Overview: Nexus HR is looking for a provider enrollment specialist with experience in coordinating the credentialing process for a reputable IPA (Independent Physician Association) company in Los Angeles. The role is primarily for provider relations while coordinating the credentialing process for any providers brought in.

About the Job

The provider enrollment specialist will be the key liaison for our providers and network, resolving issues and enhancing your understanding of our services. Your role extends to addressing inquiries from healthcare providers. Concurrently, in your position as Health Plan Credentialing Coordinator, you ensure compliance with Health Plan / IPA Guidelines and DMHCS regulations. Your duties encompass credentialing practitioners, managing applications, conducting source verifications, and maintaining QuickCap credentialing database in alignment with internal policies, client health plan contracts, state/federal requirements, and company guidelines.

Duties and Responsibilities:

1. Provider Credentialing:

• Initiate and manage the practitioner application process, overseeing document exchange, receipt, and analysis.

• Gather, verify, and evaluate confidential healthcare practitioner credentials in adherence to departmental guidelines and accreditation standards.

• Perform all aspects of credentialing verification, including initial and re-credentialing ensuring current credentials and timely file handoff or review and approval

1. Compliance and Quality Assurance:

• Ensure adherence to Health Plan and IPA guidelines throughout the credentialing process.

• Conduct comprehensive quality assurance checks to maintain accuracy and completeness of provider files.

• Stay updated on industry changes related to credentialing and communicate these changes to the team.

• Receive and respond to external provider-related issues.

1. Database Management:

• Oversee the expiration of licensure, board, and professional certifications for practitioners.

• Conduct routine audits and updates of provider files to align with organizational and regulatory standards.

• Ensure precise data entry, safeguarding the integrity of credentialing information in relevant databases.

1. Collaboration and Communication:

• Work closely with internal departments (HR, Accounting, Contracting, etc.) to streamline the credentialing process.

• Communicate effectively with healthcare professionals, addressing credentialing-related inquiries.

• Educate providers on protocols, policies, portals, and services to enhance their overall experience.

• Actively participate in team meetings and process improvement initiatives.

• Hold monthly Credentialing Committee Meeting, to discuss newly Credentialed / Re-Credentialed providers.

• Respond to practitioner, client health plan and internal inquiries in a timely manner.

• Maintain a positive, professional relationship with the provider network.

Qualifications:

• Associates’ degree or equivalent education and experience.

• Certification as a Provider Credentialing Specialist is a plus.

• 2+ years’ experience in Provider Credentialing and Provider Relations in a managed care setting.

• Knowledge of DMHC’s regulations and Health Plan / IPA Guidelines.

• Strong verbal and written communication, interpersonal, and organizational skills with meticulous attention to detail.

• Ability to research and analyze data.

• Proficient in using credential software, Microsoft Office Suite, and Google applications.

• Bilingual (English / Spanish) is highly preferred.

Benefits:

• Dental

• Vision

• Medical

• 401k

• Paid Leave

• Others