Lead, Corporate Credentialing - Remote

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 working in partnership with the Credentialing Supervisor or Manager, serving as a team lead for credentialing staff. This work may include processes involving the Credentialing Committees, clean credentialing file approvals by Medical Directors, credentialing audits and accreditation surveys, oversight of credentialing work done by vendors, developing training materials and job aids, and training staff.

Job Duties

• Oversees the day-to-day operations of the team, directs work, ensures turn-around time requirements are being met and monitors quality of work by conducting regular audits and tracking results.
• Guides and answers questions assists with interdepartmental issues to help coordinate problem solving in an efficient and timely manner.
• Monitor shared email boxes and provide answers within required time-frames.
• Supports and implements department projects.
• Provides credentialing subject matter expertise when working with other departments and functions.
• Prepares for and participates in credentialing audits and NCQA accreditations. Develops job aids and standard operating procedures and training materials.
• Prepares and presents Level 2 credentialing files for Credentialing Committee meetings.
• Scheduling and preparing materials for assigned meetings. Attends the meetings and documents meeting minutes, conducts needed follow-up after meetings.
• Documents credentialing decision and sends correspondence to providers communicating the credentialing decisions within set time-frames.
• Prepares credentialing reports for physician Medical Directors and ensures decision process is completed within set time-frames.
• Daily monitoring of aging reports.
• Working assigned data integrity reports.
• Completing member complaint reports according to procedures.
• Incorporating Recredentialing Performance Profile reports into credentialing files prior to approvals.
• Monitoring monthly metrics and aging reports, meeting with other departments to make to make necessary improvements when key performance indicators are not meeting goals.
• Daily oversight of credentialing vendors / CVO to ensure compliance with contractual requirements.
• Supports and implements department projects.

Job Qualifications

Required Education : High school diploma or GED required. Bachelor's Degree (equivalent combination of education and experience may be considered in lieu of degree). Required Experience / Knowledge Skills & Abilities : 3 years' experience in credentialing. Experience in a production or administrative role requiring self-direction and critical thinking. Extensive experience using a computer specifically internet research, Microsoft Outlook and Word, and other software systems. Experience with advanced written and verbal communication. Required knowledge of Medicaid, CMS, NCQA and other credentialing regulations. Required License, Certification, Association : Preferred Certified Provider Credentialing Specialist (CPCS) or participation in a CPCS progression program. Preferred Education : Associate or bachelor's Degree in a related field. Preferred Experience : Previous experience leading, guiding, or mentoring others.