Credentialing Clerk

MemorialCare is a nonprofit integrated health system that includes four leading hospitals, award-winning medical groups - consisting of over 200 sites of care, and more than 2,000 physicians throughout Orange and Los Angeles Counties. We are committed to increasing access to patient-centric, affordable, and high-quality healthcare; your personal contributions are integral to MemorialCare's recognition as a market leader and innovator in value-based and other care models.

Across our family of medical centers, we support each one of our bright, talented employees in reaching the highest levels of professional development, contribution, collaboration, and accountability. Whatever your role and whatever expertise you bring, we are dedicated to helping you achieve your full potential in an environment of respect, innovation, and teamwork.

The Credentialing Clerk supports Physician Billing Services by obtaining, maintaining, and renewing physician credentials with third-party payers. The position coordinates credentialing and recredentialing applications, maintains accurate and confidential physician information, monitors expiration and renewal dates, and follows up on outstanding documentation to support timely completion. The role also communicates payer approvals to relevant departments, assists the management team with obtaining PPO payer contracts for client practices, and provides support to the department and physician practices where needed.

• Obtain and maintain physician data to produce CPPA and CAQH applications for physician credentialing programs. Maintain and update provider Council for Affordable Quality Healthcare (CAQH) profiles.
• Prepare and submit payer-specified applications and enrollment packets for new credentials or recredentialing of physician clients to commercial insurance plans, including Aetna and BCBS, and government programs, including Medicare and Medicaid.Maintain a tracking mechanism on Shellpoint for submitted applications, with established follow-up procedures for incomplete credentialing applications. Track pending network applications and follow up to support timely provider approval and minimize delayed or denied patient billing.
• Notify relevant departments and parties of approved credentials when received from payers.
• Maintain organized digital or physical provider files, including physician information, supporting documents, resumes, and historical credentials, in a secure and confidential manner to prevent release to unauthorized persons.
• Documentation of request for physician data within ten business days of notification of new physician and documentation of follow-up on such open requests no less than once every five-business days until physician supplies such data.
• Number of credentialing applications completed with no denials. Goal: greater than 90%
  Verify medical licenses, board certifications, education, training, and peer references directly with primary sources.
• Monitor renewal and expiration dates for state licenses, DEA registrations, and malpractice insurance to prevent lapses in coverage.
• Query the National Practitioner Data Bank (NPDB) and Office of Inspector General (OIG) databases to check for past sanctions, malpractice history, or legal exclusions.
  Coordinate with local hospital medical staff offices to support providers in securing or renewing admitting privileges.
• Maintain current compliance documentation to support readiness for health plan or regulatory audits.
• Other duties as assigned.

Minimum skills:

• Basic computer literacy and proficiency with Microsoft Word, Excel, and Outlook; accurate typing and data entry of provider names, license numbers, dates, and other credentialing information.
• Basic administrative ability, including maintaining physical or digital filing systems, scanning documents, and operating multi-line office phones. Strong customer service skills and the ability to communicate professionally and effectively with physicians, executives, and other contacts.

Preferred experience:

• Six months to one year of general medical front office experience, such as a medical receptionist, billing clerk, or medical records assistant, with familiarity with basic medical terminology and HIPAA privacy requirements
• Prior credentialing experience is not required for entry-level applicants. An associate degree in Healthcare Administration or Business may substitute for direct medical office experience.

Minimum education:

• High school diploma or GED.
  

Certifications:

• Professional credentialing certification is not required for entry-level applicants.
• Certified Provider Credentialing Specialist (CPCS) certification issued by NAMSS is preferred.
  

Preferred education:

• Associate degree in Healthcare Administration or Business; may substitute for direct medical office experience.