Credentialing and Privileging Specialist

Summary: 

The Credentialing and Privileging Specialist is responsible for managing the end-to-end credentialing and recredentialing processes for providers within the agency. This role ensures all providers meet necessary legal, regulatory, and payer-specific standards to deliver services and bill insurance companies. The specialist acts as a liaison between providers, payers, and internal departments to ensure seamless onboarding and continued compliance with Ohio Department of Medicaid (ODM), Ohio Department of Mental Health and Addiction Services (OhioMHAS), CMS, PDMP, CAQH, and applicable professional licensing boards. 

Duties and Responsibilities 

• Prepare, submit, and monitor provider applications to insurance panels and credentialing boards in a timely and accurate manner.  

• Conduct thorough verification of licenses, certifications, education, work history, and background checks per industry standards.  

• Create and maintain accurate and up-to-date credentialing files for all providers.  

• Work directly with insurance payers to enroll new providers and ensure timely approval for network participation.  

• Ensure credentialing processes are compliant with federal and state regulations, including CMS and HIPAA standards.  

• Serve as a primary contact for credentialing-related inquiries from internal staff, providers, and insurance payers.  

• Generate and maintain reports related to credentialing status, expirable, and recredentialing timelines.  

• Complete payer enrollment and credentialing processes with Ohio Medicaid and Medicare. 

• Follow and help refine internal credentialing procedures and workflows in alignment with regulatory standards. 

Supervision Given:  

This position does not supervise any staff. 

Supervision Received: 

The Credentialling and Privileging reports to the Billing and Medical Coding Director. 

Qualifications: 

• The Credentialing and Privileging Specialist must have excellent interpersonal skills (verbal and written), organizational skills, proficiency in MS Office and ability to utilize online EHR and HRIS platforms.  

• The Credentialling and Privileging Specialist must have knowledge of Ohio website(s) (PNM) for credentialling and recredentialling purposes.  

• This position must also understand and follow HIPAA, HIPAA 42CFR compliance, and HIPAA EDI standards (837, 835, 270/271, 276/277, 278). 

• Knowledge of NH, IN and WV credentialing a plus.  

Education:  

A High school diploma with experience noted below is required. 

Certification: None Required 

Experience: 2–5 years of credentialing and privileging behavioral health setting. 

Physical Effort: 

Requires sitting for long periods of time, viewing computer monitors, and keyboarding. Must be able to lift 20 pounds. 

Background: 

Must pass all Federal and State background checks. Other background checks will be conducted for licensures and certifications according to company policy. 

Schedule: 

Full-Time, 

Benefits: 

This position is eligible for Medical Benefits, Dental Benefits, Paid Time Off, and Paid Holidays.