Credentialing And Enrollment Specialist

Overview: Planned Parenthood of Orange and San Bernardino Counties has a full-time opportunity for a Credentialing and Enrollment Specialist in Anaheim, CA.
The Specialist will complete initial credentialing, maintain credentialing packets and work with external credentialing consultants to ensure all providers are in active status while employed with PPOSBC. Specialist will ensure all providers are credentialed as required by Medicaid, IPA, ARMS and other medical regulatory agencies. Other responsibilities will include guiding PPOSBC patients through the insurance change process to enroll in Melody Health. The Specialist will assist with membership reporting and enrollment marketing campaigns to increase Melody Health patient base. The Specialist is responsible for monthly monitory of Melody Health Enrollment numbers within PPOSBC’s gender and age bands. Scope includes in-reach/outreach and collaboration with internal departments to maximize enrollment efforts in Melody Health. The Specialist is responsible for cleaning the monthly payer roster and generating the Payroll incentive report for each pay period.

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.

• Maintains the timelines on enrollment/credentialing schedules, communicates with providers and health plans to update as needed and maintain a strict level of confidentiality for all matters pertaining to provider credentials processing.
• Obtains credentialing data needed for onboarding, contracting, and other related purposes. Credentialing data includes but is not limited to the medical degree, Drug Enforcement Administration (DEA) number, CDS, state licenses, Board certifications, CV, malpractice insurance etc.
• Monitor and track submissions and status changes with payers and update internal records.
• 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.
• Assist and partner in community outreach activities in collaboration with the Community Education/Outreach and Public Affairs Departments.
• Coordinate enrollment efforts by staff and track monthly performance by Health Centers.
• Walk patients through Melody enrollment process and confirm with payer.
• 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.
• Leverage marketing campaigns to enroll patients into Covered CA and Medi-Cal to grow Melody Health.
• Build rapport with contracted health plan member service departments to assist patients in choosing a primary care provider.
• Monitor monthly rosters from payers and provider patient panels.
• Ongoing confirmation of health plan directories for patient access and provider demographics.

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.

• 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.

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.
• Sales experience preferred.
• Knowledge of health plan system preferred.
• 2-3+ years’ experience with provider enrollment and credentialing.
• Credentialing experience with a managed care setting preferred.

Other Requirements:

• This position requires travel to other sites and locations; if using a personal vehicle to meet this requirement, a valid CA driver’s license and current auto insurance in compliance with the minimum requirements of CA vehicle code are required.
• This position prefers bilingual Spanish skills (reading, writing, and speaking). Qualified candidates will be tested for proficiency prior to offer.

All employees are required to be fully vaccinated for COVID-19 unless a reasonable accommodation is approved for a medical/disability or religious exemption.

Planned Parenthood/Orange and San Bernardino Counties is an equal opportunity employer. Applicants will receive consideration for employment without regard to race, color, ancestry, national origin, religion, creed, equal pay, age, disability, sex, gender, sexual orientation, gender identity, gender expression, medical condition, genetic information, marital status, military, veteran status or any other federal or state protected class. We are committed to building and maintaining an inclusive workplace that values diversity, equity, and inclusion.