Director – Credentialing and Provider Information Management (PIM) in Orange at Prospect Medical Systems

Date Posted: 9/17/2020

Job Snapshot

  • Employee Type:
  • Location:
    600 City Parkway West
  • Job Type:
  • Experience:
    Not Specified
  • Date Posted:
  • Job ID:

Job Description

Director – Credentialing and Provider Information Management (PIM)

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.

The Credentialing and Provider Information Management (PIM) Departments provide Credentialing and practitioner data management services for practitioners affiliated with Prospect. This position reports to the “Vice President - Credentialing, PIM, PMO” and directs/ manages the operations of the Credentialing and Provider Information Management Departments including, but not limited to, the planning, organizing, monitoring, development of activities/ procedures, risk mitigation to assure compliance with NCQA, CMS, DHS, State, and all Health Plan credentialing requirements.  Credentialing/PIM Director will be the key department liaison between Health Plans, other regulatory agencies and Prospect and will assist with leading and overseeing all Credentialing and PIM related deliverables. She/he will be responsible for ensuring timely processing of the initial files and re-credentialing files for owned and managed providers and ancillaries within compliance guidelines for multiple states. Also responsible for ensuring the accuracy of practitioner data in both internal databases and health plan directories, timely roster submissions and manage the submissions and term process. Responsibilities include full credentialing function and compliance for any newly owned or managed or acquired entities. Leadership is key. Committee management, Systems management, CVO management, all HP, state, DMHC, downstream audits, processes, production, quality, timely and accurate reporting to required entities are key. Credentialing/PIM Director will achieve the department objectives efficiently, effectively and within agreed upon time, cost and performance criteria and lead both teams governed by the approved policies and procedures.   Will need to participate and deliver on complex required deliverables (projects, reports, enhancements, Health Plan inquiries, audits) and manage excellent relationship with multi-functional teams, while maintaining excellent communication with management and the Executives.  Uses independent judgment, strategy, initiative, and tact, completing assignments with minimal to no supervision. Must be collaborative, solution oriented and with great leadership skills to be able to provide clear directions to the teams including guidance and mentoring.

Job Responsibilities/Duties

  • Responsible for credentialing/PIM leadership and management of credentialing/PIM process for providers, HDOs.
  • Plan develop and coordinate activities/procedures to assure compliance with NCQA, CMS, DHHS, ICE, CMS, and other health plan requirements.
  • Oversees, develops, and maintain systems, database programs, reports for credentialing and PIM. Proactively invest in understanding the requirements of the departments and help develop and maintain key quality metrics
  • Responsible for maintenance of all credential files, other relevant provider and ancillary focused information and maintain data integrity.
  • Assure reappointment process is initiated for each practitioner and ancillaries and is completed prior to 36month cycle.
  • Help lead and coordinate key credentialing audits, develop responses for HP inquiries and ensure department compliance with all required audits and lead and corrections that is requires within the committed timeline with the Health Plans
  • Research and develop meaningful responses for regulatory bodies in response to their queries
  • Ensure departmental Policy and Procedure Manual are kept at minimum to NCQA standards. Manage P&Ps and ensure they are compliant on an on-going basis
  • May require leading system replacement project design, conversion from operations standpoint. Will require same due diligence and compliance for newly acquired business.
  • Ensure CVO compliance
  • Work closely with Legal Counsel, Compliance, Government Programs, Executives and the VP on strategic decisions and directions.
  • Analytical responsibilities for credentialing information management and reporting is required.
  • Responsible for monthly, quarterly, and semi-annual reporting of credentialing/PIM activities to health plans.
  • Responsible for initial recommendations regarding bylaws revision, deletions, additions.  Provide updates to health plans as required, once recommendations are approved
  • Lead committees efficiently, organizes meetings, prepared agenda, prepares and sends files to the committee ahead of time. Manages monitoring information. Oversight and review of monthly sanction monitoring.
  • Summarize statistics and committee minutes for monthly reporting to Credentialing Committees, Management, and other relevant departments.
  • Serves as direct liaison between Network Management, Contracting, Compliance, Med Mgmt. and other related departments and help resolve issues and bottle necks.
  • Directs department to meet needs of organization and requirements of regulatory agencies.
  • Effective leading and management of resources and providing guidance to the teams. Educate, direct, motivate, manage Credentialing/PIM staff to assess performance, meet daily production goals with superior quality. Pro-actively manage departments training to avoid CAPs. Enhance processes to reduce deficiencies.
  • Manage performance of employees and provide on-going feedback and reviews. Help set goals that are aligned with company goals.
  • Help document processes, standard operating procedures (SOPs) for team for consistent and compliant systems.
  • Plan, organize, and direct network-wide Credentialing Department.
  • Work closely with VP to ensure all Credentialing Department administrative functions and meet set budget.


Minimum Education: Bachelor's degree preferred. NCQA, JC knowledge is required.

Minimum Experience: Ten (10) years’ experience in similar fields and/or training/experience in credentialing in a hospital or IPA setting is required. Previous Director role helps but must have managerial experience. Compliance, Contracting, Provider Data Management or equivalent combination of education and experience will be highly recommended and preferred. 

Req. Certification/Licensure: CMSC or CPCS preferred.

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: