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Duke University Health System
Durham, North Carolina
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Details
Posted: 06-Mar-25
Location: Los Angeles, California
Internal Number: 146532506
Description
While working with the Manager of Quality Management and Credentialing, the Credentialing Specialist will be responsible for ensuring the accuracy of provider data entered into the provider database as well as participating in the activities required for credentialing oversight as defined by departmental policy. This position is accountable for consistently maintaining production and quality standards in accordance with departmental policy. Also, as a member of the Credentialing Team, the Credentialing Specialist will receive incoming provider and member inquiries and will need to identify potential trends and follows-up with providers, members and internal departments ensuring identified problems have been resolved.
This position works as a team member with providers, provider’s office staff and all departments within UCLA Health System. The Credentialing Specialist will adhere to NCQA, State, Federal and other Regulatory agency standards as it pertains to the responsibilities of the position.
Additional responsibilities include:
- Auditing credentialing files and ensuring compliance with NCQA, DOD, DHS, and CMS standards. Assists with NCQA certification activities.
- Attending monthly Credential Committee meetings and presents credentialing information as needed.
- Producing accurate and timely credentialing reports to meet contractual obligations.
- Maintaining knowledge of provider participation rules and assists staff and members with credentialing inquiries.
- Ensuring provider demographic information is accurate and updated in relevant databases.
- Maintaining accurate and timely documentation of all credentialing related transactions.
- Organizing and maintaining provider credentialing files and related documents.
- Ensuring provider complaints are documented and reported during recredentialing.
- Monitoring and tracks provider license and certification expirations to ensure timely renewals.
- Completing and following up on provider credentialing and recredentialing applications.
- Maintaining records of provider licenses, DEA certificates, malpractice coverage, and other
Salary Range: $26.10 - $49.38 Hourly
Qualifications
- High school diploma, GED or equivalent experience required
- Minimum two years or more experience working for a Health Plan, IPA, or other Managed Care Organization required
- Working knowledge and experience with provider credentialing requirements required
- Strong organizational skills and the ability to manage aggressive timelines and prioritize multiple concurrent tasks while maintaining high quality standards
- Proficient computer skills including Microsoft Excel and Word. Competence in navigating the internet
- Excellent customer service and interpersonal skills, with an ability to work with internal and external representatives
- Willingness to learn new technologies, practices and procedures
- Extensive knowledge of managed care operations, including IPAs, multi-specialty medical groups, etc., basic policies and procedures in claims, authorizations, eligibility, and customer service
- Comprehensive knowledge, understanding, and implementation of provider and HMO contracts
- Strong leadership skills, with the ability to work independently and under time pressure and the ability to motivate others to perform to achieve departmental goals and objectives
- Excellent verbal and written communication skills
About UCLA
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