Lead, National Credentialing

Molina Healthcare•Long Beach, CA

About The Position

JOB DESCRIPTION Job Summary Provides lead level support for Molina enterprise credentialing activities. Ensures that the Molina provider network consists of providers that meet all regulatory and risk management criteria - effectively minimizing liability to the company and maximizing safety for members. Responsible for initial credentialing, recredentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations in the Molina network. Essential Job Duties In collaboration with credentialing leadership, assists in oversight of the day-to-day operations of the credentialing team; directs work, ensures turn-around time requirements are met, and monitors quality of work by conducting regular audits/tracking results. Provides credentialing subject matter expertise internally within the credentialing department, and to other departments and functions as needed. Prepares for and participates in credentialing audits and National Committee for Quality Assurance (NCQA) accreditations. Develops credentialing job aids, standard operating procedures (SOPs) and training materials. Prepares and presents level II credentialing files for credentialing committee meetings. Schedules and prepares materials for assigned meetings; attends meetings, documents meeting minutes, and conducts necessary follow-up. Guides and answers questions assists with interdepartmental issues to help coordinate credentialing-related problem-solving in an efficient and timely manner. Monitors shared email boxes and provides answers within required time-frames. Documents credentialing decision and sends correspondence to providers communicating the credentialing decisions within set time-frames. Prepares credentialing reports for physician medical directors, and ensures decision process is completed within set time-frames. Facilitates daily monitoring of aging reports. Completes assigned data integrity reports. Completes member complaint reports according to procedures. Incorporates recredentialing performance profile reports into credentialing files prior to approvals. Monitors monthly metrics and aging reports; meets with other departments to make to make necessary improvements when key performance indicators (KPIs) do not meet goals. Facilitates daily oversight of credentialing vendors/CVO to ensure compliance with contractual requirements. Maintains a high level of confidentiality related to provider information. Provides training, mentoring, and support to new and existing credentialing team members. Provides support for credentialing projects.

Requirements

At least 4 years of experience in provider credentialing, or equivalent combination of relevant education and experience.
Knowledge of Centers for Medicare and Medicaid Services (CMS), National Committee for Quality Assurance (NCQA) and other credentialing-related regulations.
Data entry skills, and production-related experience.
Self-direction and logical thinking abilities.
Internet research experience.
Ability to work cross-collaboratively in a highly matrixed organization with internal/external stakeholders.
Effective verbal and written communication skills.
Microsoft Office suite and applicable software programs proficiency.

Nice To Haves

Certified Provider Credentialing Specialist (CPCS) or participation in a CPCS progression program.

Responsibilities

Assists in oversight of the day-to-day operations of the credentialing team
Provides credentialing subject matter expertise internally within the credentialing department, and to other departments and functions as needed.
Prepares for and participates in credentialing audits and National Committee for Quality Assurance (NCQA) accreditations.
Develops credentialing job aids, standard operating procedures (SOPs) and training materials.
Prepares and presents level II credentialing files for credentialing committee meetings.
Schedules and prepares materials for assigned meetings; attends meetings, documents meeting minutes, and conducts necessary follow-up.
Guides and answers questions assists with interdepartmental issues to help coordinate credentialing-related problem-solving in an efficient and timely manner.
Monitors shared email boxes and provides answers within required time-frames.
Documents credentialing decision and sends correspondence to providers communicating the credentialing decisions within set time-frames.
Prepares credentialing reports for physician medical directors, and ensures decision process is completed within set time-frames.
Facilitates daily monitoring of aging reports.
Completes assigned data integrity reports.
Completes member complaint reports according to procedures.
Incorporates recredentialing performance profile reports into credentialing files prior to approvals.
Monitors monthly metrics and aging reports; meets with other departments to make to make necessary improvements when key performance indicators (KPIs) do not meet goals.
Facilitates daily oversight of credentialing vendors/CVO to ensure compliance with contractual requirements.
Maintains a high level of confidentiality related to provider information.
Provides training, mentoring, and support to new and existing credentialing team members.
Provides support for credentialing projects.