Credentialing Quality Assurance Auditor - Full Time

We are hospitals and affiliated medical groups, working closely together for the benefit of every person who comes to us for care. We build comprehensive networks of quality healthcare services that are designed to offer our patients highly coordinated, personalized care and help them live healthier lives. Through collaboration, we strive to provide all of our patients and medical group members with the quality, affordable healthcare they need and deserve.

This position performs credentialing and re-credentialing file and system data entry audit activities according to Prospect Medical Credentialing Policies, contracted health plan policies, CMS, DMHC, and NGQA accreditation guidelines. This position acts as a liaison between our IPAs and contracted health plans.

Job Responsibilities/Duties

Conduct Credentialing and Re-credentialing file audits per NCQA, CMS, DMHC and health plan standards/policies.

Conduct Morrisey system record data entry audits for each credentialing and re-credentialing file.

Credential cases

Demonstrate and maintain credentialing knowledge.

Keep abreast of new and changing regulations and standards.

Train staff on audit errors.

Assist in staff maintaining an 80% accuracy rate.

Assist Credentialing Manager and Supervisor with health plan corrective action plan responses and corrections Conduct health plan audit file prep.

Handle health plan audit file submissions and information including submission of current P&Ps, delegation agreements, rosters, monitoring information and HIV information.

Conduct audits on health plan roster submissions to ensure information is accurate.

Conduct audits on change forms being submitted to health plans to ensure accuracy of information and submission.

Minimum Education: Bachelor's degree or equivalent.

Minimum Experience: Previous credentialing or delegation auditor experience with a minimum of five years IPA/Medicla Group or Health Plan experience required.

Req. Certification/Licensure: None.

Employee Value Proposition

Prospect Medical Holdings, Inc., is guided by a diverse and highly experienced leadership core. This group maintains the vision that has made Prospect a needed difference-maker in the lives of so many patients today, and many executives contribute to our continued efforts. As a member of our highly effective team of professionals you will receive:

Company 401K

Medical, dental, vision insurance

Paid time-off

Life insurance
Prospect Medical Systems has a zero-tolerance policy regarding the use of drugs and alcohol. Our Company is committed to maintaining a productive, drug free workplace that keeps employees and patients safe from harm. For this reason, we require applicants to pass a screening for drug use as a condition of employment. This includes: alcohol, marijuana, cocaine, opiates and methamphetamines.

How to Apply

To apply for this role, or search our other openings, please visit and click on a location to begin your journey to a new career with us!

We are an Equal Opportunity/ Affirmative Action Employer and do not discriminate against applicants due to veteran status, disability, race, gender, gender identity, sexual orientation or other protected characteristics. If you need special accommodation for the application process, please contact Human Resources.

EEOC is the Law:

Keywords: Credentialing, Audit, Assurance, Quality Improvement, Quality, Quality Assurance

Job Details:

Posted Date : 2022-05-07

Job type : Full Time

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