Credentialing Specialist

Job Summary

We are seeking a detail-oriented and organized Medical Credentialing Specialist to join our healthcare team. The role involves managing and maintaining the credentialing and re-credentialing process for healthcare providers to ensure compliance with industry standards, regulatory requirements, and payer guidelines. The ideal candidate will play a critical role in ensuring seamless provider onboarding and credentialing processes.

Key Responsibilities

1. Credentialing and Re-Credentialing:
   Manage the end-to-end credentialing process for healthcare providers, including obtaining and verifying necessary documentation (e.g., licenses, certifications, and education).
   Maintain accurate and up-to-date provider information in credentialing databases.
2. Compliance:
   Ensure compliance with state, federal, and payer regulations.
   Monitor credentialing expirations and manage timely renewals of licenses, certifications, and insurance enrollments.
3. Verification and Communication:
   Perform primary source verification of education, training, licensure, and work history.
   Communicate with insurance companies, hospitals, and other healthcare organizations to ensure provider enrollments are completed.
4. Database Management:
   Maintain and update credentialing software and systems with accurate provider records.
   Generate regular reports on credentialing status and compliance metrics for management review.
   Work closely with providers, administrators, and third-party payers to resolve credentialing issues promptly.
   Assist in streamlining credentialing workflows to enhance efficiency.
5. Audits and Reporting:
   Prepare for and assist in internal and external audits related to credentialing.
   Provide timely reporting on credentialing statuses and compliance performance.

Required Skills & Qualifications

• High school diploma or equivalent (Bachelor's degree in Healthcare Administration or related field preferred).
• Minimum of 1-2 years of experience in medical credentialing or a related role.
• Knowledge of credentialing and privileging processes, including payer enrollment requirements.
• Familiarity with credentialing software and systems (e.g., CAQH, NPPES, or Verity).
• Strong attention to detail and organizational skills.
• Excellent verbal and written communication skills.
• Ability to work independently and handle sensitive information confidentially.

Preferred Qualifications

• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) certification.
• Experience with Medicare and Medicaid credentialing processes.
• Understanding of healthcare regulations and compliance standards (e.g., HIPAA).