Credentialing and Audit Specialist

JOB SUMMARY:

The Credentialing and Audit Specialist is a critical role responsible for ensuring that all medical staff and allied health credentialing, recredentialing, and privileging processes comply with NCQA credentialing standards, state and federal regulations, accreditation requirements (e.g., AO, CMS), and organizational policies. Responsible for maintaining an integrated database for Ephraim McDowell Health, Cooperative Care Network, Central Kentucky Physicians, Inc., Ephraim McDowell Health Resources and the Centralized Application Verification Organization. The Associate coordinates and maintains complete, survey‑ready credentialing files and databases, supports internal and external audits, and provides administrative support to Medical Staff Services and related committees. The position requires exceptional organizational skills, attention to detail, and independent work management in a highly confidential and sensitive environment. The successful candidate will demonstrate a proactive approach to credentialing, audit readiness, and policy adherence while exhibiting the values of Friendliness, Innovation, Respect, Service, and Trust.

ESSENTIAL FUNCTIONS, DUTIES AND RESPONSIBILITIES:

Regulatory, NCQA, and Compliance Responsibilities (Mandatory)

• Ensure the organization's credentialing and recredentialing processes comply with NCQA standards, Kentucky state licensure regulations, Accrediting Organization requirements, CMS Conditions of Participation, and other applicable regulatory or accreditation bodies.

• Monitor changes in coordination with the audit specialist credentialing‑related regulations and NCQA standards. Assist with communication for relevant updates to Medical Staff Services leadership for incorporation into policies and procedures.

• Assist in the development, review, and maintenance of Medical Staff Bylaws, Rules and Regulations, Credentialing Policies, and Procedures to align with current laws, accreditation standards, and NCQA elements.

• Maintain personal adherence to professional confidentiality standards established within the Department and in accordance with legal, ethical, and organizational policies.

• Assure data security and confidentiality of all files by securing appropriate file areas, cabinets, drawers, and computer terminals.

Credentialing, Recredentialing, and Privileging (Mandatory)

• Coordinate initial credentialing, recredentialing, and privileging activities for physicians and allied health practitioners in accordance with Medical Staff Bylaws, credentialing plans, and NCQA standards.

• Process new and reappointment applications, including application intake, completeness review, primary source verification, identification and follow‑up of discrepancies, and preparation for committee and Board review.

• Ensure all required elements are obtained and documented (e.g., licenses, DEA, malpractice insurance, board certification, work history, malpractice history, sanctions, health status, references) within required NCQA and regulatory timeframes.

• Maintain an integrated credentialing database for all providers, including demographic information, privileges granted, department and committee appointments, credentialing history, and reappointment dates.

• Closely monitor information collection and follow up to obtain missing or expiring documents; ensure credentialing files are orderly, current, and consistently survey‑ready.

• Coordinate and document privileging decisions, including any conditions or limitations, and ensure privileges are accurately entered and maintained in applicable systems.

• Assist with processing temporary or disaster privileges in accordance with bylaws and regulatory standards, ensuring appropriate documentation and approvals.

Audit and Delegation Oversight Support (Mandatory)

• Support internal and external credentialing audits, including payer delegation, cooperative care/clinically integrated network audits, and accreditation or state surveys.

• Understand how to audit credentialing files, policies, committee minutes, and tracking tools required by payers and surveyors to demonstrate compliance with NCQA and regulatory credentialing standards.

• Conduct periodic internal self‑audits of credentialing and privileging files, identify gaps or deficiencies, and assist in developing and tracking corrective action plans.

• Maintain thorough documentation of audits, findings, corrective actions, and follow‑up activities in accordance with organizational and regulatory expectations.

Medical Staff Meetings and Governance Support (Mandatory)

• Assist in the preparation of agendas, credentialing and privileging reports, and supporting documents for Medical Staff Committees.

• Attend assigned medical staff or committee meetings, record accurate minutes, and prepare final minutes for review and approval within established timeframes.

• Ensure credentialing and privileging actions are properly documented and that approved actions are accurately reflected in provider files and databases.

• Coordinate meeting logistics, including room scheduling, audiovisual arrangements, catering requests, and distribution of meeting materials as needed.

Student, Resident, and Training Program Support (Mandatory where applicable)

• Coordinate credentialing‑related onboarding activities for students, residents, fellows, and other learners per affiliation agreements and organizational policy.

• Process and track documentation required for rotations (e.g., immunizations, background checks, letters of good standing, required training), and ensure any permitted access or limited privileges are documented.

• Maintain accurate logs and records of student and resident participation, ensuring documentation is available for accreditation and audit review.

Residency, Experience, and Privilege Verification (Mandatory)

• Respond to internal and external requests for verification of appointment, privileges, and training for current and former practitioners in accordance with confidentiality and release‑of‑information policies.

• Prepare and issue standardized verification letters and forms, ensuring content is accurate and reviewed/approved per departmental protocol.

• Maintain logs of verification requests and responses to support audit trails and risk management needs.

Office and Administrative Responsibilities (Mandatory)

• Perform general office duties for the Medical Staff Services Department, including answering telephones, greeting visitors, handling mail, scanning, copying, and filing documents.

• Maintain organized credentialing and departmental files (electronic and paper), ensuring quick retrieval and secure storage.

• Monitor and maintain inventory of office supplies and coordinate service or repair of departmental office equipment.

• Complete all typing, correspondence, reports, and other clerical work necessary to facilitate efficient department operations.

Systems, Data Integrity, and Reporting (Mandatory)

• Maintain accurate data in medical staff/credentialing software and related databases for all practitioners across applicable facilities and networks.

• Perform routine data quality checks and self‑audits to ensure consistency between electronic and paper records and to support NCQA and accreditation expectations.

• Develop and run reports (e.g., expirables, pending applications, reappointment lists, committee/Board actions) as requested by Medical Staff Services leadership and Administration.

• Assist Information Services and vendors with implementation of software updates or enhancements, and provide basic end‑user support and training for credentialing‑related systems.

Communication, Education, and Collaboration (Mandatory)

• Communicate effectively with physicians, allied health professionals, students, departmental leaders, and support staff regarding credentialing requirements, file status, and timelines.

• Provide basic education to providers and staff regarding credentialing processes, NCQA expectations, documentation standards, and best practices for maintaining complete and timely files.

• Serve as a resource for Medical Staff and Administrative projects as assigned.

WORKING CONDITIONS, HAZARDS, AND PHYSICAL EFFORT:

Works in an office environment. May require extended hours. Normal hours are Monday–Friday, 8:30 a.m.–5:00 p.m. Minimal risk exposure to disease, infection, physical strain, or exposure to blood, body fluids, and tissue. This may result in periods of increased levels of stress. High degree of stationary position and time spent at a computer terminal. Must be able to move or position 25 lbs independently

CONTACTS WITH OTHERS:

Has contact with all individuals who utilize, visit or conduct business with Ephraim McDowell Regional Medical Center or visit the administrative offices. Including Administrative Officer, Medical Staff, Board Members, Directors, Associates, Visitors and Patients. Contact with other agencies include Medical Licensure Boards, Accrediting and Regulatory Agencies, Internship and Residency Programs, Insurance Agencies, Medical Colleges, Educational Commission for Foreign Medical Graduates, Federal and National Agencies (American Medical Association, Federation State Medical Board, Drug Enforcement Agency, National Practitioner Data Bank), Physician Recruiting agencies, travel agencies, hotels, and car rental agencies.

EQUIPMENT USED/SPECIAL SKILLS REQUIRED:

• Strong knowledge of credentialing and privileging processes, Medical Staff Bylaws, NCQA standards, and accreditation/regulatory requirements.

• Ability to interpret complex regulations and standards and apply them effectively to credentialing operations.

• Exceptional organizational and time‑management skills with the ability to handle multiple priorities and deadlines.

• Proficiency in medical staff/credentialing software and data analysis/reporting tools; intermediate to advanced computer skills (e.g., word processing, spreadsheets, databases, email).

• Excellent written and verbal communication skills for interacting with physicians, providers, leaders, auditors, surveyors, and Associates.

• Ability to maintain confidentiality and handle sensitive information with discretion.

• Ability to perform basic gap analysis and assist with development and monitoring of action plans.

• Intermediate typing speed (e.g., 50 words per minute) with accuracy.

Minimum of 3 years of experience in the medical field, with credentialing, medical staff services, or compliance roles strongly preferred.

Familiarity with Kentucky state regulations, accrediting organization standards, NCQA credentialing standards, and related regulatory/quality expectations highly preferred.