Job Summary:
The Credentialing Specialist will be responsible for ensuring all providers are properly credentialed and in compliance with state and federal regulations, payer requirements, and internal standards. The role includes coordinating and processing applications, maintaining credentialing databases, and submitting malpractice documentation as required.
Supervisory Responsibilities:
None.
Duties/Responsibilities:
- Coordinate and manage the full cycle of provider credentialing and re-credentialing for physicians and advanced practice providers.
- Gather, verify, and review documentation including licenses, education, training, certifications, work history, references, and malpractice history.
- Submit and track malpractice insurance applications, renewals, and updates, ensuring continuous coverage for all providers.
- Maintain and update credentialing databases and internal records accurately and timely.
- Facilitate enrollment and re-enrollment with insurance payers, ensuring all providers are properly listed and billing can proceed without interruption.
- Monitor and track expiration dates of licenses, certifications, and other credentials to ensure timely renewals.
- Respond to credentialing-related inquiries and requests from internal departments, insurance companies, and regulatory bodies.
- Communicate with physicians and advanced practice providers regarding outstanding documents and application statuses.
- Ensure compliance with regulatory, accrediting, and contractual requirements.
- Prepare and submit credentialing reports and summaries for leadership as needed.
- Performs other duties as assigned.
Required Skills/Abilities:
- Strong organizational skills and attention to detail
- Proficiency with credentialing software and MS Office Suite
- Excellent verbal and written communication skills
- Ability to manage multiple priorities and meet deadlines in a fast-paced environment
- Familiarity with NCQA, CMS, and commercial insurance credentialing standards
- Working knowledge of provider enrollment with Medicare, Medicaid, and commercial payers.
Education and Experience:
- High school diploma or equivalent required; Associate’s or Bachelor’s degree in healthcare administration or a related field preferred
- Minimum 2–3 years of credentialing experience, preferably in a healthcare environment
- Experience with physician credentialing and malpractice submissions preferred
Physical Requirements:
- Prolonged periods of sitting at a desk and working on a computer
Report job
