Healthcare Credentialing Specialist
Company: EXCEL MSO
Location: San Jose
Posted on: April 6, 2021
Physicians Medical Group of San Jose / Excel MSO is looking for
the best and brightest professionals to handle the business side of
medical practice so "doctors can be doctors." We are fortunate to
have experienced unprecedented growth in the last few years – and
we're just getting started. As the largest Independent Physicians
Association in Santa Clara County, not only do we partner with the
most health plans, but we're also the first Clinically Integrated
Network in SiliconValley.
We deeply trust and value our dedicated physicians and employees
who provide compassionate care to our 100,000+ patients every day.
If you are looking for a rewarding opportunity with an innovative,
collaborative, and inspirational team, join us at PMGSJ / Excel
MSO, and help us continue to be trailblazers in the transformation
of health care.
JOB DESCRIPTIONResponsible for leading, coordinating, monitoring,
and maintaining the credentialing and re-credentialing process.
Facilitates all aspects of medical group credentialing, including
initial appointment, reappointment, expired processes, as well as
clinical privileging for Medical Staff,Allied
Health Professionals, and all other providers outlined in the
medical group's Bylaws, policies, or related contracts. Ensures
interpretation and compliance with the appropriate accrediting and
regulatory agencies, while developing and maintaining a working
knowledge of the statues and laws relating to credentialing.
Responsible for the accuracy and integrity of the credentialing
database system and related applications. Maintains up-to-date data
for each provider in credentialing databases and online systems;
ensure timely renewal of licenses and certifications. Works under
the supervision of the Vice President of Provider Network
ESSENTIAL DUTIES AND RESPONSIBILITIES
1. Leads, coordinates, and monitors the review and analysis of
practitioner applications and accompanying documents, ensuring
applicant eligibility. Ensure application timeliness per
2. Conducts thorough background investigation, research and primary
source verification of all
3. Identifies issues that require additional investigation and
evaluation, validates discrepancies and ensures appropriate follow
up. Contact practitioners to clarify discrepancies.
4. Prepares credentials file for completion and presentation to the
Credentialing Committees, ensuring file completion within time
periods specified. Collaborate with the Chair of the
Credentialing Committee to ensure that all significant malpractice
cases, state/federal sanctions, and quality issues are reviewed
prior to the Credentialing Committee.
5. Processes requests for privileges, ensuring compliance with
criteria outlined in clinical privilege descriptions.
6. Responds to inquiries from other healthcare organizations,
interfaces with internal and external customers on day-to-day
credentialing and privileging issues as they arise.
7. Assists with delegated credentialing audits; conducts internal
8. Utilizes the CVO (Credentialing Verification Organization)
credentialing database, optimizing efficiency, and performs query,
report and document generation; submits and retrieves
NationalPractitioner Database reports in accordance with Health
Care Quality Improvement Act.
9. Monitors the initial, reappointment and expiring processes for
all medical staff, Allied Health Professional staff, Other Health
Professional staff, and delegated providers, ensuring compliance
with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal
and Credentialing Coordinator job description state), as well as
Medical Staff Bylaws, Rules and Regulations, policies and
procedures, and delegated contracts.
10. Submit all required reports to contracted Health Plans in the
allocated time frame
11. Arranges, organizes, and coordinates the Credentialing
Committee meetings including: a. Email reminders to members to
ensure a quorum b. Prepare agendas, files and needed materials
c.Assemble meeting packets and/or adhoc meetings d. Plan and
schedule meeting space and order catering for meeting e. Take
minutes, complete follow up correspondence, and send out all
Provider communication regarding decisions made by the
Credentialing Committee with approval from the Board meeting
12. Performs miscellaneous job-related duties as assigned
• Bachelor's Degree
• Minimum 6 years of experience with 4 years directly related to
hospital medical staff or managed care credentialing.
• Certification/Licensure NAMSS Certification as a Certified
Professional Medical Services Manager (CPMSM) or Certified Provider
Credentials Specialist (CPCS) or actively pursuing
• Completed degree(s) from an accredited institution that are above
the minimum education requirement may be substituted for experience
on a year for year basis.
• Knowledge of CMS, DHCS, DMHC, NCQA standards and Title XXII
• Knowledge of commonly-used concepts, practices and procedures
used in health care credentialing.
• Sound knowledge and understanding of Credentialing Committee
• Possess excellent organizational skills and attention to
• Ability to maintain strict adherence to deadlines.
• Ability to function well within a team environment and
• Ability to communicate effectively, both orally and in
• Program planning and implementation skills.
• Knowledge of related accreditation and certification
• Knowledge of medical credentialing and privileging procedures and
• Ability to analyze, interpret and draw inferences from research
findings, and prepare reports.
• Working knowledge of clinical and/or hospital operations and
• Informational research skills.
• Ability to use independent judgment to manage and impart
• Database management skills including querying, reporting, and
• Ability to make administrative/procedural decisions and
• Constant and close visual work at a desk or computer.
• Constant sitting and working at a desk.
• Constant data entry using a keyboard and/or mouse.
• Constant use of telephone headset.
• Frequent verbal and written communication with Providers,
internal staff and other business associates by telephone,
correspondence, or in person.
• Frequent walking and standing.
• Lifting infrequent, up to 25 lbs. weight.
• Current CA driver's license and insurance
Keywords: EXCEL MSO, San Jose , Healthcare Credentialing Specialist, Healthcare , San Jose, California
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