Credentialing Specialist (2026)

Position Summary

The Credentialing Specialist is responsible for facilitating requests for initial appointment, clinical privileges, re-appointment, and annual review in compliance with HRSA, CMS, Indian Health Services (IHS), health plan policies, Medical Staff Bylaws, NCQA Accreditation Standards, FTCA requirements, and federal and state regulations. This role also manages payer enrollment and revalidation processes for both individual providers and the organization’s facilities, including CMS forms 855I, 855B, and 855A. The Credentialing Specialist serves as a key liaison between clinical leadership, Human Resources, and operational departments to ensure timely and compliant onboarding, enrollment, and privileging of providers across all payer types.

Essential Duties/Responsibilities

• Congduct primary source verification and data collection for all medical staff and clinical privilege applicants, including reappointments, per all regulatory requirements and timelines.

• Advise medical staff leadership of potential issues, investigate as required, and escalate major concerns to the Manager.

• Establish and maintain credential files in an organized and compliant manner for all assigned Practitioners, OLCPs, and clinical staff.

• Facilitate review and approval of completed credentialing files with prior to submission to the Governing Board.

• Maintain strict confidentiality throughout the credentialing and privileging process.

• Enter new applications and updates into credentialing software and maintain current file status records.

• Aid Patient Accounts with Medicare/Medicaid enrollment, revalidation, and related changes.

• Produce monthly reports on upcoming licensure and immunization renewals for managers.

• Monitor provider profiles in CAQH, PECOS, PAVE and NPPES to ensure consistency across systems.

• Coordinate NPPES updates with the Compliance or Administrative team as needed.

• Complete required credentialing, re-credentialing, and privileging applications for provider enrollment in commercial payers, Medicare, and Medicaid.

• Coordinate and submit enrollment applications for Medicare (PECOS), Medi-Cal (PAVE), and commercial payers for all new providers and locations.

• Manage timely revalidations and updates across all payers, including tracking of submission deadlines and confirmations.

• Complete and maintain CMS enrollment forms, including CMS 855A, 855I, and 855B, ensuring accuracy and alignment with Tribal and FQHC scope of services.

• Monitor and update provider and facility enrollment status across PECOS, NPPES, CAQH, and other relevant databases.

• Serve as a liaison with CMS and state Medicaid agencies regarding enrollment discrepancies or follow-up.

• Oversee CMS facility revalidation processes, including timely submission of documentation to maintain active Medicare enrollment for the organization.

• Coordinate with leadership to address any changes in ownership, service location, or compliance scope.

• Collaborate with Billing staff to resolve authorization and denial issues.

• Maintain individual provider files with updated information for necessary credentialing applications.

Qualifications

• Must be at least 18 years of age.

• High school diploma or equivalent.

• Three (3) years equivalent experience in a clinic setting with knowledge of federal and state credentialing requirements.

• Bachelor’s degree preferred.

• Must be or willing to obtain CPCS or CPMSM certification from the National Association Medical Staff Services.

• Valid CPR Certification.

• Valid California Driver’s License.