Credentialing Specialist Department:

Provider Relations /

Credentialing Organization:

AllCare IPA Position Type:

Full-Time -

In Person FLSA Status:

Non-Exempt Location:

Modesto, California Salary:

$25.00- $30.00 per hour. Wages based on experience Position Summary The Credentialing Specialist is responsible for coordinating and completing initial credentialing and recredentialing activities for healthcare providers participating in AllCare IPA's provider network. The position ensures credentialing files are complete, accurate, appropriately verified, and processed within established timelines and in accordance with AllCare IPA requirements and applicable health plan credentialing requirements. The Credentialing Specialist works closely with providers, provider offices, internal departments, health plans, and other external organizations to obtain and verify credentialing information, resolve discrepancies, maintain accurate provider records, and support timely provider participation in the network. Essential Duties and Responsibilities Initial Credentialing, Recredentialing and Provider Onboarding Coordinate the initial credentialing process for physicians and other healthcare practitioners seeking participation with AllCare IPA. Review credentialing applications and supporting documents for completeness and accuracy. Communicate with provider offices regarding incomplete applications, discrepancies, or outstanding documentation. Assist with provider onboarding by ensuring applicable credentialing requirements are completed before network participation. Process provider requests to join the network and assist with determining whether required threshold documentation has been received. Obtain, review, track, and verify applicable provider credentials, including: o Professional licensure o DEA registration o Hospital privileges o Board certification o Medical education and postgraduate/residency training o Professional liability insurance o Medicare program-related sanctions or adverse actions and applicable exclusion information o Other documentation required by AllCare IPA or contracted health plans. Maintain tracking systems for outstanding applications and required documentation. Ensure recredentialing files are completed within established timelines. Prepare complete credentialing and recredentialing files for review by the appropriate Credentialing Committee and Board. Coordinate distribution of Board-approved, applications, and provider notification/congratulatory letters as appropriate. Serve as a resource to provider offices regarding credentialing requirements and outstanding documentation. Develop effective working relationships with providers and office staff to facilitate timely responses and resolve credentialing issues. Collaborate with Provider Relations and other internal departments on provider onboarding, demographic updates, network participation, and related projects. Assist with provider outreach and other departmental projects assigned. Provider Data & File Maintenance Maintain accurate and complete electronic and/or physical credentialing records. Update provider demographic and credentialing information as changes are received. Maintain and verify hospital privilege and board certification information. Monitor credentialing documents for expiration and obtain updated documentation as appropriate. Maintain accurate documentation to support internal and external audits. Maintain applicable NPDB-related credentialing information. Support credentialing activities in accordance with AllCare IPA credentialing/recredentialing policies and procedures and applicable contracted health plan requirements. Assist with credentialing audits by ensuring provider files contain complete, accurate, and appropriately maintained documentation. Minimum Qualifications Education High school diploma or equivalent required. Associate degree or additional healthcare administration education preferred. Experience Prior experience in healthcare credentialing, provider enrollment, medical staff services, managed care, health plan operations, or a related healthcare administrative role preferred. Experience working with physician/provider documentation and confidential information preferred. Knowledge, Skills & Abilities Working knowledge of healthcare credentialing and recredentialing processes. Strong attention to detail and ability to identify discrepancies in provider documentation. Excellent organizational and follow-up skills. Ability to manage multiple provider files and competing deadlines. Strong written and verbal communication skills. Professional communication skills when interacting with physicians, provider office staff, health plans, and internal departments. Strong computer skills, including Microsoft Outlook, Word, and Excel. Ability to work independently while contributing effectively within a team environment. Ability to prioritize urgent requests and adjust to changing departmental needs. Preferred Qualifications Previous credentialing experience within an IPA, medical group, health plan, hospital medical staff office, or managed care organization. Familiarity with provider credentialing applications and primary-source verification. Familiarity with NPDB and provider exclusion/sanction verification. Familiarity with Medicare Advantage provider network requirements. Benefits AllCare offers fully paid employee benefit package including health, vision, dental, LTC and employer matched 401k with immediate vesting. Please send a resume to jobs@allcareipa.com or AllCare, 3320 Tully Road Modesto, CA 95350

Attn:

Human Resources.

Pay:

$25.00 - $30.00 per hour

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Paid time off

Work Location:

In person