Responsible for validation, investigation and reporting of practitioners' credentials and sanctions information to the credentialing committee.Ongoing monitoring of sanctions and activities related to the credentialing and re-credentialing for BSC provider.Processes provider initial applications, re-credentialing applications, prepping committee sanction report and communication with BSC delegated medical groups.Maintains provider sanction information up to date in CACTUS.
Gathers data, reviews for completeness and accuracy, analyzes potential problems, take appropriate actions and prepare committee reports.
Monitors timeliness in receipt of information and follows-up as needed.
Identifies questionable or highly sensitive information and refers to appropriate sources for further research.
Enters credentialing data into system and tracks and maintains provider information.
Performs general office duties such as indexing, sorting, mail distributions, etc.
Require communication and distribution with internal departments on sanction activities and inconsistencies in findings.
Identifies procedural and systems problems and brings them to Supervisor's attention; makes recommendations where appropriate.
Maintains CACTUS data, monitoring logs and all report sites from state and federal to track sanction activities.
Review reports from regulatory agencies and review them on timely as required by BSC timeline.
May summarize provider files or disciplinary actions to facilitate committee review or prepare detailed documentation related to formal reviews.
Other duties as assigned by the manager.
Education and Experience
Requires basic job knowledge of systems and procedures obtained through prior work experience or education.
Requires minimum of 2 years credentialing experience. Preferably in Health Plan setting.
Effective written and oral communication skills and ability to handle sensitive information and issues with tact and discretion.
About Company: Looking for a chance to do meaningful work that touches millions? Come join the hardest working, nonprofit health plan in California and help us shape the future of health care. Blue Shield of California is focused on transforming health care by making it more accessible, affordable and customer-centric. Being a mission-driven organization means we do much more than serve our 3.5 million members: we were the first health plan in the nation to limit our annual net income to 2 percent of revenue and return the difference to our customers and the community, and since 2005 we have contributed more than million to the Blue Shield of California Foundation to improve community health and end domestic violence. We also believe that a healthier California begins with our employees, so we provide them with resources to develop and maintain a healthy lifestyle through our award-winning wellness program, Wellvolution. We're hiring smart thinkers and doers who want to work for a leader and innovator in the challenging, ever-changing healthcare space. Come and help us make health care better for everyone.
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