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Credentialing Specialist (Temporary)

Job ID 2017501 Date Posted 10/16/2020 Location Burlingame, California Schedule/Shift Temporary/Contract/ Day

Thank you for your interest in temporary contract opportunities with RightSourcing at Sutter Health and wanting to assist our team that proudly cares for more than 3 million of our neighbors across Northern California.

Position Overview:

Job Summary:

This position is responsible for completion of credentialing functions. Ensures program integrity and compliance with standards, federal/state requirements, and Health Plan Credentialing Requirements. Assists Supervisor in maintaining relationships with Health Plan Auditors; communicates and works with Physician leaders on credentialing issues; works with other departments in multiple areas that relate to credentialing issues. Audits Credentialing Verification Organization’s released files to ensure it obtains primary source verification of required physician information. Maintains database of current and accurate information concerning licensure, board certification, professional liability coverage and claims for all PMC and MPMG Physicians, Contracted Providers and Allied Health Professionals. Manages the provider add process, recruitment and transition, including the successful appointment to the Mills-Peninsula Provider Network in accordance with the Credentials Policies & Procedures and regulatory agency requirements.


  • The Credentialing Specialist shares in the responsibility of resolving credentialing related issues with Managed Care Staff, Managed Care Contracting Department, Quality Improvement Department, Receivables Management and required follow up. This includes the credentialing processes for MPMG and PMC physicians.
  • Completes all necessary steps to add/terminate a provider from the Mills-Peninsula Network. Duties include providing contracted health plans with necessary provider status/information changes and responding to health plan initiated inquiries and timely follow-up with Health Plans to ensure their websites have updated information. Works effectively with other departments including 1) Contracting department to ensure that appropriate paperwork to add, terminate, panel closures, changes in TIN, changes to practice name, name changes and status changes are entered into appropriate databases in a timely and complete manner. 2) Eligibility Department resolves issues with the eligibility downloads identified by the Eligibility Department and 3) Receivables Management Department on timely notification of Medicare/Medi-Cal and Health plan enrollment and resolution of enrollment status issues. Works with HP PR reps to ensure errors are accurately corrected.
  • The Credentialing Specialist ensures that the providers are initially credentialed and re-credentialing within the standard timeframe.

    In a timely manner, informs UM manager and PR Representative of necessary provider site visits that need to be conducted. Upon completion of the credentialing and re-credentialing process responsible for timely notification to providers of their status within the Network,

    Maintains the credentialing database and ensures it is up-to-date and accurate. Updates provider directories.

  • Manages and prepares for scheduled Credentials Sub-Committee meeting, including Pre-CCM’s

    Maintains the MPN Credentialing Program, including but not limited to the preparation of the agenda and ensures minutes are accurate and timely.

    Assists in updating Policies and Procedures when necessary to comply with NCQA, IMQ standards and Health Plan delegated credentialing requirements.

    Assists with Delegated Health Plan audits and subsequent follow up.

    Assists in preparation of files for audits, Corrective Action Plans, policy revisions and policies for CAPS when required.

    Assists Supervisor when needed in working with Chief Medical Officer on policy revisions with subsequent approval by the Governing Bodies.

    Works with Supervisor to assure that the department successfully complies with contracted health plans regulation and ICE audits

  • Ensures all necessary documentation submitted to CMS, State of CA, Health Plans and SPS is timely and accurate so that PMC providers are accurately loaded and are able to provide services to Medicare, Medi-Cal and Health Plan members
  • Assists Supervisor by providing technical leadership and assistance with systems, technical issues, equipment, current compliance and regulatory requirements, assistance with problems that arise
  • Assist Supervisor in training staff when necessary

  • Assist in completing routine monthly monitoring functions, including verifying that providers have renewed Board Certifications and professional licenses that are due to expire and review of websites to identify whether contracted providers have reported incidents

  • All other duties as assigned and considered appropriate within the position as currently described, and as the position evolves within MPN
  • Follows the commitment to excellence and treats patients, families, visitors and each other with courtesy, dignity, respect and professionalism

Required: High School diploma or equivalent; Bachelors Degree, CPCS or CPMSM certification highly desired.
  • Knowledge of applicable regulations, guidelines, policies & procedures and contractual provider agreements
  • Customer Service focused
  • Healthcare experience

Organization: Mills-Peninsula Health Services
Employee Status: Temporary
Position Status: Non-Exempt
Union: No
Job Shift: Day
Shift Hours: 8 Hour Shift
Days of the Week Scheduled: Monday-Friday
Weekend Requirements: None
Schedule: Full Time
Hrs Per 2wk Pay Period: 80

Sutter Health Affiliates are equal opportunity employers EOE/M/F/Disability/Veterans

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