Credentialing Specialist

Key Responsibilities

• Create and maintain comprehensive digital records of provider licensing, credentials, and malpractice insurance.
• Manage provider profiles in industry databases (e.g., CAQH, PECOS, NPPES) with high accuracy.
• Monitor expiration dates for licenses, DEA certificates, board certifications, and insurance policies.
• Issue "renew by" notifications to staff and management well in advance to prevent coverage lapses.
• Act as the primary point of contact for external agencies, hospitals, and commercial payers requesting verification of provider information.
• Stay current on updated state, federal, and payer-specific regulations (including NCQA and CMS standards) to ensure organizational policies remain compliant.
• Assist in developing and revising internal credentialing Standard Operating Procedures (SOPs) to improve workflow efficiency and data integrity.
• Ensure the facility and all staff members maintain continuous compliance to ensure readiness for internal or external audits at any time.

Qualifications

• Required: High School Diploma or GED. Bachelor’s degree or college coursework in Health Administration, Business, or a related field.
• PREFERRED: Minimum of 2 years of experience in medical billing, credentialing, provider enrollment, or medical office administration.
• Proficiency with provider enrollment platforms (Medicare, Medicaid, Commercial Payers).
• Strong knowledge of medical credentialing policies, healthcare regulations, and accreditation standards.
• Exceptional accuracy in data entry and document verification.
• Communicator: Strong verbal and written communication skills, with the ability to speak professionally with clinicians and insurance representatives.
• Organizer: Ability to meet strict deadlines and prioritize tasks in a fast-paced environment without compromising quality.
• Team Player: Willingness to collaborate with the billing and authorization teams while possessing the self-discipline to work independently.