Credentialing Specialist

POSITION DESCRIPTION:

The Credentialing Specialist is responsible for managing and maintaining the credentialing and recredentialing process for healthcare providers and clinical staff. This position ensures that provider credentials, licenses, certifications, and other required documentation are accurate, current, and compliant with organizational, regulatory, insurance, and accreditation requirements. Adheres to Corporate Compliance program, by reporting improper or unethical conduct, violation of applicable laws, regulations or program requirements

DUTIES AND RESPONSIBILITIES:

• Manage initial credentialing, recredentialing, and ongoing credential maintenance for healthcare providers and clinical staff.
• Collect, verify, and maintain provider information, including licenses, certifications, education, training, work history, malpractice coverage, and professional references.
• Conduct primary source verification of provider credentials in accordance with applicable standards and organizational policies.
• Maintain accurate provider and clinical staff records in credentialing databases and electronic systems.
• Monitor expiration dates for licenses, certifications, registrations, malpractice insurance, and other required credentials.
• Initiate and track credentialing applications with commercial insurance plans, Medicare, Medicaid, and other payers, as applicable.
• Follow up with providers and clinical staff, licensing boards, hospitals, educational institutions, professional organizations, and insurance companies to obtain required documentation.
• Identify missing, incomplete, or inconsistent information and resolve discrepancies in a timely manner.
• Prepare credentialing files and documentation for review by credentialing committees and other authorized decision-makers.
• Maintain confidentiality and protect sensitive provider and organizational information.
• Ensure credentialing activities comply with applicable regulatory, accreditation, payer, and organizational requirements.
• Assist with audits, reporting, and quality-control activities related to credentialing and provider enrollment.
• Maintain tracking logs and generate reports regarding credentialing status, expirations, applications, and outstanding items.
• Communicate professionally with providers, internal departments, payers, regulatory agencies, and external organizations.
• Perform other credentialing, provider enrollment, and administrative duties as assigned.

KNOWLEDGE, SKILLS AND ABILITIES:

• Knowledge of credentialing, provider enrollment, and primary source verification processes.
• Ability to manage multiple providers, applications, and deadlines simultaneously.
• Strong attention to detail and ability to manage confidential information.
• Excellent organizational, written, and verbal communication skills.
• Proficiency with Microsoft Office, Excel and electronic databases, provider management or credentialing systems.

TRAINING AND EXPERIENCE:

• High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business, or a related field preferred.
• 1–3 years of experience in healthcare credentialing, provider enrollment, medical staff services, or a related healthcare administrative role.
• Experience with CAQH, PECOS, NPPES, Medicare/Medicaid enrollment, and commercial payer enrollment preferred
• Familiarity with NCQA, CMS, AAAHC, HRSA, and other applicable credentialing or regulatory standards preferred
• Certified Provider Credentialing Specialist (CPCS) or Certified Provider Enrollment Specialist (CPES) certification is a plus.