Credentialing Specialist

Job Description:

Purpose - The Junior to Mid Credentialing Specialist supports the accurate and timely credentialing and recredentialing of healthcare providers with insurance networks, clearinghouses, and other credentialing bodies. This role involves assisting the Senior Credentialing Specialist in maintaining compliance, ensuring accurate documentation, and coordinating with insurance networks and other credentialing entities.

Key Responsibilities

Credentialing and Recredentialing Support:

• Assist the Senior Credentialing Specialist in preparing, submitting, and tracking provider enrollment applications for insurance networks and credentialing organizations.

• Ensure the accuracy and completeness of provider credentialing documentation, including licenses, certifications, and insurance coverage.

• Monitor and update credentialing timelines, ensuring compliance with deadlines and payer requirements.

Compliance and Documentation:

• Perform primary source verifications as directed, maintaining adherence to regulatory and organizational standards.

• Maintain organized credentialing records and ensure accurate data entry in credentialing software or databases.

• Assist in audits of credentialing files to verify compliance with HIPAA and other regulatory requirements.

Communication and Coordination:

• Act as a liaison between the Senior Credentialing Specialist, healthcare providers, and external entities to resolve credentialing-related issues.

• Follow up with providers, payers, and clearinghouses to gather required information or clarify discrepancies.

• Communicate updates on credentialing processes and progress to the Senior Credentialing Specialist and management.

Administrative Support:

• Provide support during high-volume credentialing periods, including managing overflow tasks as assigned by the Senior Credentialing Specialist.

• Prepare reports and summaries of credentialing activities for review by the Credentialing Manager or team.

• Assist in training new team members on credentialing processes and software.

Required Knowledge and Skills:

• Basic knowledge of credentialing processes and healthcare regulations.

• Strong organizational skills with exceptional attention to detail and accuracy.

• Proficiency in credentialing software and Microsoft Office Suite (Word, Excel, Outlook).

• Excellent verbal and written communication skills for interacting with internal and external departments.

• Ability to multitask and work collaboratively in a fast-paced environment.

Additional Requirements

• Education: College or equivalent required; an Associate’s degree in healthcare administration or a related field is preferred.

• Experience:

  • At least 1-3 years of administrative experience, preferably in healthcare or credentialing.

  • Familiarity with credentialing software and US payer processes is an advantage.

• Attributes: Proactive, team-oriented, and capable of handling sensitive information professionally.

Work Environment

• Office-based or remote, depending on organizational needs.

• May require flexibility during high-demand periods to meet deadlines.

Shift / Hours:

Monday Friday in one single shift, 9:00 AM EST - 6:00 PM EST. Note this is +12 or +13 Philippine time, which will be 9:00 PM PHT 6:00 AM in PHT.