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The Senior Credentialing Representative - San Diego, CA will be responsible for the full range of system of care provider relations and service interactions. Maintains and ensures the integrity of provider databases; responds to provider inquiries and provides exceptional customer service to providers, County partners, peers, staff in other departments and the general public.
As part of this position, you will be required to be granted and maintain access to the County of San Diego’s electronic health record, Cerner Community Behavioral Health (CCBH). In addition, please note that if you are currently employed by the County of San Diego, further review of your application will need to occur to ensure that there is not a conflict of interest.
- Receive and review application material to determine if system of care providers meet qualifying criteria for credentialing and have supporting documents to ensure compliance with the credentialing criteria
- Provide oversight and compare application information to credentialing sources to ensure accuracy and completeness of provider application information
- Ensure verifications are completed within state, federal, and/or internally mandated timeframes (e.g., NCQA; CMS)
- Scan system of care provider credentialing information into applicable systems to follow document management and retention procedure
- Receive and/or gather information from applicable databases regarding provider quality and performance (e.g., disciplinary notices)
- Review reports (e.g., disciplinary reports; monthly reports; Medicaid reports) from state licensing bodies to determine if affected providers are within the system of care network and recommend appropriate follow-ups
- Contact primary sources, credentialing agencies, and/or reference on-line information sources in order to verify system of care provider credential information (e.g., licenses; education; Board certification; DEA and/or CDS)
- Verify that appropriate signatures on credentialing applications have been obtains and follow corporate and/or state signature procedures
- Tracks credentialing process and sends provider documentation that credentialing and re-credentialing processes are completed
- Runs reports from provider databases to track credentialing and re-credentialing activities for the variety of provider types
- Facilitates the tracking of providers’ malpractice insurance, DEA, and licensure renewals to ensures they are current/active
- Facilitates the resolution of credentialing issues and coordinates and completes external and internal notification requirements
- Attend and participate in meetings to achieve departmental and interdepartmental goals, objectives, and handle follow-up activities
- Oversee and organize provider files which are easily reviewed by staff, credentialing committee and external review bodies
- Documents communication with system of care providers and/or administrative organization in the designated databases; assists in managing the integrity of databases by using contacts with providers to verify and update provider files
- Assume additional responsibilities as assigned
- High School Diploma / GED or higher
- Proficient with Microsoft Excel (general spreadsheet navigation, data entry and data sorting), Microsoft Word (creating and editing documents) Outlook (email and calendar)
- 2 + years data entry experience
- 1 + years working in an environment that requires coordination of benefits and utilization of multiple groups and resources
- Knowledge of industry terminology (e.g., medical; dental; behavioral health)
- Knowledge of applicable state and federal laws, policies, and regulations (e.g., state-specific license requirements; Controlled Dangerous Substances license requirements; DEA)
- Knowledge of credentialing procedures, policies, and terminology (e.g., NCQA; URAC)
- Knowledge of provider information storage and retrieval systems (ie: CAQH, National Practitioner Data Bank (NPDB) or similar)
- Knowledge using data analytics of key operating indicators (e.g., quality percentages; turnaround time) or performance standards experience
- Requires up to 25% local San Diego travel to provider sites
- Associate’s Degree preferred
- Previous experience in managed care credentialing preferred
- MS Excel (pivot tables and vlook ups)
Careers with Optum. Here's the idea. We built an entire organization around one giant objective; make the health system work better for everyone. So when it comes to how we use the world's large accumulation of health-related information, or guide health and lifestyle choices or manage pharmacy benefits for millions, our first goal is to leap beyond the status quo and uncover new ways to serve. Optum, part of the UnitedHealth Group family of businesses, brings together some of the greatest minds and most advanced ideas on where health care has to go in order to reach its fullest potential. For you, that means working on high performance teams against sophisticated challenges that matter. Optum, incredible ideas in one incredible company and a singular opportunity to do your life's best work.SM
Diversity creates a healthier atmosphere: UnitedHealth Group is an Equal Employment Opportunity/Affirmative Action employer and all qualified applicants will receive consideration for employment without regard to race, color, religion, sex, age, national origin, protected veteran status, disability status, sexual orientation, gender identity or expression, marital status, genetic information, or any other characteristic protected by law.
UnitedHealth Group is a drug-free workplace. Candidates are required to pass a drug test before beginning employment.
Keywords: Credentialing, Controlled Dangerous Substances, credentialing procedures, NCQA, URAC, CAQH, NPDA, National Practitioner Data Bank, San Diego, CA, Optum