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Molina Healthcare Associate Specialist_Corporate Credentialing in Spokane, Washington

KNOWLEDGE, SKILLS & ABILITIES (Generally, the occupational knowledge and specific technical and professional skills and abilities required to perform the essential duties of this job):

Responsible for coordinating assigned aspects of enterprise-wide credentialing and primary source verification process for practitioners and health delivery organizations according to Molina policy and procedure. Where possible, specific production goals on a weekly or monthly basis will be tracked for each respective accountability. Maintains a high level of confidentiality for provider information.

Duties to include any combination of the following:

• Processing Credentialing Applications.

• Evaluates credentialing applications for accuracy and completeness based on differences in provider specialty and obtains required verifications as outlined in Molina policies/procedures and regulatory requirements, while meeting production goals.

• Communicates with health care providers to clarify questions and request any missing information.

• Updates credentialing software systems with required information.

Recredentialing/Termination.

• Requests recredentialing applications from providers and conducts follow-up on application requests, following department guidelines and production goals.

• Collaborates with internal and external contacts to ensure timely processing or termination of recredentialing applicants.

• Completes data corrections in the credentialing database necessary for processing of recredentialing applications.

• Reviews claims payment systems to determine provider status, as necessary.

Ongoing Monitoring/Watch Follow-up.

• Completes follow-up for provider files on ‘watch’ status, as necessary, following department guidelines and production goals.

• Reviews and processes assigned federal/state and license sanctions and exclusions reports to determine if providers have sanctions/exclusions.

• Reviews and processes monthly Medicare Opt-Out reports to determine if any provider has opted out of Medicare.

• Reviews and processes assigned NPDB Continuous Query reports and takes appropriate action when new reports are found.

JOB FUNCTION:

Molina's Credentialing function ensures that the Molina Healthcare provider network consists of providers that meet all regulatory and risk management criteria in order to minimize liability to the company and to maximize safety for members.

REQUIRED EDUCATION:

High School Diploma or GED.

REQUIRED EXPERIENCE:

• Experience in a production or administrative role requiring self-direction and critical thinking.

• Extensive experience using a computer -- specifically internet research, Microsoft Outlook and Word, and other software systems.

• Experience with professional written and verbal communication.

REQUIRED LICENSE, CERTIFICATION, ASSOCIATION:

PREFERRED EDUCATION:

Post-high school education in administration or health care.

PREFERRED EXPERIENCE:

Experience in the health care industry.

PREFERRED LICENSE, CERTIFICATION, ASSOCIATION:

PHYSICAL DEMANDS:

Working environment is generally favorable and lighting and temperature are adequate. Work is generally performed in an office environment in which there is only minimal exposure to unpleasant and/or hazardous working conditions. Must have the ability to sit for long periods. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

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