Job Description: Description: To initiate the credentialing and ASC privileging of all practitioners employed or contracted with Kaiser Permanente of the Mid- Atlantic States, in compliance with federal, state, local laws and regulations and all applicable accreditation standards.
Initiates and follows through on all aspects of credentialing and ASC privileging including the initial and recredentialing process for all practitioners. Conducts primary source verification of practitioner's background, education/training and malpractice history through the use of on-line systems, written correspondence, telephone inquiries and printed reference guides, rosters and reports. Performs List Validation and Reporting (LVAR) queries, Databank and sanction queries per the MASCAP policies. Identifies and evaluates potential red flags and works in collaboration with department Manager/Director, and/or Physician Managers to determine next steps.
Coordinates approval of identified clean files at weekly electronic meetings of the MASCAP committee and initiates notification of committee decision to practitioner with appropriate follow-up to MAPMG/Health Plan HR and Provider Relations.
Responsible for preparation of materials and files for presentation and review by the MASCAP committee.
Ensures compliance with NCQA standards and other regulatory agencies. Assists in the development of policies and procedures to support the credentialing process.
Responsible for the accuracy and integrity of the credentialing database. Able to run database queries and reports to support efficiencies and prioritization of workflow.
Provides assistance and determines resolution to practitioner issues and triages appropriately, via verbal/written communication in response to both internal and external customers.
Basic Qualifications: Experience
One of the following:
Minimum four (4) years of credentialing experience in a managed care setting;
Minimum two (2)years of credentialing experience in a managed care setting and an associate's degree required. Education
AA degree required, OR two (2) years of experience in a directly related field.
High School Diploma or General Education Development (GED) required. License, Certification, Registration
Strong organizational and communication skills required.
Proven ability to function independently with minimal direct supervision required.
Excellent verbal and written skills are required and the ability to multi-task.
Significant knowledge of Federal and State regulatory requirements and accreditation standards, including NCQA, CMS, COMAR, AAAHC, Medicare and Medicaid required.
Bachelor's degree preferred.
Certification as a Certified Provider Credentialing Special (CPCS) preferred.
Knowledge of Visual Cactus preferred. Primary Location: Maryland,Rockville,Rockville Regional Offices 2101 E. Jefferson St. Scheduled Weekly Hours: 40 Shift: Day Workdays: Mon, Tue, Wed, Thu, Fri Working Hours Start: 8:30 AM Working Hours End: 5:00 PM Job Schedule: Full-time Job Type: Standard Employee Status: Regular Employee Group/Union Affiliation: Non-Union, Non-Exempt Job Level: Individual Contributor Job Category: QA / UR / Case Management Department: Practitioner and Provider Quality Assurance Travel: No Kaiser Permanente is an equal opportunity employer committed to a diverse and inclusive workforce. Applicants will receive consideration for employment without regard to race, color, religion, sex (including pregnancy), age, sexual orientation, national origin, marital status, parental status, ancestry, disability, gender identity, veteran status, genetic information, other distinguishing characteristics of diversity and inclusion, or any other protected status.
External hires must pass a background check/drug screen. Qualified applicants with arrest and/or conviction records will be considered for employment in a manner consistent with federal and state laws, as well as applicable local ordinances, including but not limited to the San Francisco and Los Angeles Fair Chance Ordinances.