Quality Assurance Reviewer

Department: Ops - Credentialing

Employment Type: Full Time

Location: 1600 Corporate Center Dr., Monterey Park, CA 91754

Reporting To: Isela Ochoa

Compensation: $59.00 - $60.00 / hour

Description

The Quality Assurance Reviewer ensures healthcare providers are appropriately credentialed with health plans and regulatory agencies. This role involves maintaining accurate records, submitting applications, and ensuring compliance with industry regulations. As the primary liaison between healthcare providers and health plans, the coordinator ensures timely and efficient completion of credentialing processes.

What You'll Do

• Review and process healthcare providers’ credentialing applications to ensure compliance with health plan participation requirements.
• Verify providers’ professional qualifications, including education, licensure, and certifications.
• Maintain and update credentialing records for all providers within the health plan network.
• Submit credentialing applications to health plans for review and approval.
• Monitor re-credentialing timelines, ensuring timely renewal of certifications, licenses, and memberships.
• Ensure compliance with federal, state, and health plan-specific regulations and policies.
• Collect required documentation from providers, including diplomas, licenses, certifications, and malpractice insurance.
• Address and resolve discrepancies or issues encountered during the credentialing process.
• Protect the confidentiality of sensitive provider and patient information.
• Assist with audits and respond to health plan inquiries regarding credentialing status.
• Collaborate with internal departments to resolve credentialing-related issues and maintain accurate data
  
  

Qualifications

• High school diploma or equivalent.
• Proven experience in credentialing within a health plan or managed care setting.
• Strong knowledge of credentialing procedures and regulatory standards for health plans.
• Proficiency in Microsoft Office Suite (Word, Excel, Outlook).
• Excellent organizational skills and attention to detail.
• Ability to maintain confidentiality and manage sensitive information.
• Effective written and verbal communication skills.
  
  

Preferred Qualifications

• Certification from a credentialing organization (e.g., National Association of Medical Staff Services, NAMSS).
• Experience using credentialing software or databases.
• Familiarity with medical terminology and healthcare provider networks.
  
  

Environmental Job Requirements and Working Conditions

• Our organization follows an hybrid work structure where the expectation is to work onsite 2 days a week. This position will report to our Monterey Park corporate office at 1600 Corporate Center Drive.
• The total pay range for this role is: $22-24/hr. This salary range represents our national target range for this role.