Credentialing Specialist - REMOTE

Job Description

Job Description Job Summary Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria to minimize liability to the company and to maximize safety for members. This position is responsible for the initial credentialing, re-credentialing and ongoing monitoring of sanctions and exclusions process for practitioners and health delivery organizations according to Molina policies and procedures. This position is also responsible for meeting daily/weekly production goals and maintaining a high level of confidentiality for provider information. Responsible for coordinating assigned aspects of enterprise-wide credentialing and primary source verification process for practitioners and health delivery organizations according to Molina policy and procedure. Where possible, specific production goals on a weekly or monthly basis will be tracked for each respective accountability. Maintains a high level of confidentiality for provider information. Typically assigned the more complex work; works on special projects as assigned; and serves as a "mentor" to newly hired Associate Specialists. Job Duties • Processing Credentialing Applications • Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals. • Communicates with health care providers to clarify questions and request any missing information. • Updates credentialing software systems with required information. Recredentialing/Termination • Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals. • Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants. • Completes data corrections in the credentialing database necessary for processing of recredentialing applications. • Reviews claims payment systems to determine provider status, as necessary. Ongoing Monitoring/Watch Follow-up • Completes follow-up for provider files on 'watch' status, as necessary, following department guidelines and production goals. • Reviews and processes assigned daily alerts for federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions. • Reviews and processes monthly daily alerts for Medicare Opt-Out reports to determine if any provider has opted out of Medicare. • Reviews and processes assigned daily NPDB Continuous Query reports and takes appropriate action when new reports are found. Job Qualifications Required Education: High School Diploma or GED Required Experience/Knowledge Skills & Abilities: Certified Provider Credentialing Specialist (CPCS) or participation in a CPCS progression program. Preferred Education: Bachelor's Degree in a related field Preferred Experience: Previous experience leading, guiding, or mentoring others. To all current Molina employees: If you are interested in applying for this position, please apply through the intranet job listing. Molina Healthcare offers a competitive benefits and compensation package. Molina Healthcare is an Equal Opportunity Employer (EOE) M/F/D/V. Apply Job!