Enrollment & Credentialing Specialist (Administrative)

Planned Parenthood of Orange and San Bernardino Counties has a full-time opportunity for an Enrollment & Credentialing Specialist in Anaheim, CA.

The Enrollment and Credentialing Specialist is responsible for completing initial credentialing and re-credentialing. The Specialist will ensure that all providers are in active status while employed with Planned Parenthood Orange and San Bernardino Counties (PPOSBC). This includes ensuring all providers are credentialed and re-credentialed in compliance with Medicaid, IPA, Health Plans, and other medical regulatory agencies. The Specialist will also manage platforms such as CAQH and PAVE. In addition to credentialing duties, the Specialist will guide PPOSBC patients through the insurance change process to enroll in Melody Health. The Specialist is responsible for generating monthly and monitoring the PCP Switch Payroll incentive report. 

At PPOSBC, we understand the importance of a well-rounded benefits program and are dedicated to providing you with unique benefits that meet the needs of you and your family. We are proud to offer a range of plans that help protect you in the case of illness or injury including:

• A competitive benefits package including medical, dental, and vision coverage for you and eligible dependents, life insurance, and long term disability. 
• Benefits coverage starts after one full month of employment!
• Generous vacation, sick, and holiday benefits!
• Generous 401(k) matching contributions and more!
• To view our detailed benefits guide, please visit our career site at www.pposbccareers.org

Responsibilities

Essential Functions: Essential functions encompass the required tasks, duties and responsibilities performed as part of the job and the reason the job exists.

• Process and complete initial credentialing and re-credentialing for providers.
• Manage and update credentialing information in CAQH.
• Obtains credentialing data needed for provider credentialing, contracting, and other related purposes. Credentialing data includes but is not limited to the medical degree, Drug Enforcement Administration (DEA) number, state licenses, Board certifications, CV, malpractice insurance, etc.
• Monitor and track credentialing submissions and status changes with payers and update internal records.
• Assist providers with their Medi-Cal enrollment applications through the PAVE portal, ensuring accurate submissions.
• Obtains credentialing data needed for provider credentialing, contracting, and other related purposes. Credentialing data includes but is not limited to the medical degree, Drug Enforcement Administration (DEA) number, state licenses, Board certifications, CV, malpractice insurance, etc.
• Monitor and track credentialing submissions and status changes with payers and update internal records.
• Serve as the point of contact for providers regarding credentialing, enrollment, and PAVE processes, ensuring clear and timely communication.
• Educate patients on the importance of health care coverage and answer questions pertaining to the health care system as it relates to enrollment.
• Assist with patient retention efforts and reporting.
• Educate patients on primary care services offered at Melody Health.
• Coordinate enrollment efforts by staff and track monthly performance by Health Centers.
• Walk patients through Melody enrollment process and confirm with HealthPlan/IPA portals.
• Generate incentive report every pay period based on number of confirmed Melody switches.
• Maintain and report accurate daily/weekly/monthly statistical records to track productivity.
• Build rapport with contracted health plan member service departments to assist patients in choosing a primary care provider.
• Ongoing confirmation of health plan directories for patient access and provider demographics.
• Review and monitor Health plan updates regularly from various health plans.
• Filter and organize the Health plan information. Identify and filter out updates that do not apply to our organization, ensuring only relevant information is retained
• Accurately enter and organize applicable health plan updates into a Word document to ensure information is well-documented and easily accessible for reference
• Provide organized updates to the appropriate PPOSBC Departments in a timely manner
• Work closely with team members to ensure accurate and efficient processing of health plan updates

 

Non-Essential Functions:

• Other duties as assigned.

PHYSICAL REQUIREMENTS:

The physical requirements of this position are identified below. Reasonable accommodations may be made for individuals with disabilities to perform the essential functions of this position.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

 

Minimum Education:

• Associate or undergraduate degree Preferred.
• High School Diploma or GED equivalent Required.

 

Minimum Work Experience:

• Knowledge and understanding of HIPAA and PHI regulations required.
• Knowledge and experience with health plans or healthcare industry.
• 2-3+ years' experience with provider enrollment and credentialing.
• Credentialing experience with a managed care setting.

 

Other Requirements:

• Work well with diverse communities that are uninsured/underinsured.
• Understanding of Health Care Reform and Covered California Exchange Market preferred.
• Overall excellent people and customer service skills.
• Ability to work flexible hours and weekends as needed.
• Ability to build on and leverage existing resources within organization.
• Ability to work effectively and efficiently in a fast-paced environment.
• Ability to motivate others and work collaboratively with team members.
• Ability to stay up to date with current changes in health care.
• Must be able to work independently, be self-motivated and demonstrate high attention to detail.

 

Agency Standard Requirements:

• Strong commitment to quality healthcare and excellent customer service is required.
• Must thrive in a fast paced, rigorous environment with changing priorities.
• Ability to meet deadlines and work under pressure.
• Must demonstrate high level computer skills including; Microsoft Word, Excel and Outlook. Electronic medical records experience may also be required.
• Abortion patients are cared for at each of our health centers and in part through the administrative, support, and other non-clinical services provided at all PPOSBC locations and by all PPOSBC employees, and supporting these critical services is an essential job duty and fundamental responsibility of all employees.