Credentialing Specialist

3 weeks ago

Rawalpindi Cantonment, Pakistan 24-7 Consultancy Full time

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).
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