Credentialing Specialist

Schedule: Monday - Friday, 8:00 AM - 5:00 PM

Pay: TBD

Education level: Associate's or Bachelor's Degree. See Education and/or Experience.

Friendship Community Care is seeking a highly organized Credentialing Specialist. The ideal candidate will have experience with healthcare credentialing, provider enrollment, compliance documentation, and license verification in a healthcare, behavioral health, or human services environment.

SUMMARY:

The Credentialing Specialist will manage provider credentialing, licensure tracking, and payer enrollment for healthcare professionals. This role ensures all licensed providers meet state regulatory, Medicaid, Medicare, and insurance payer requirements prior to delivering services.

ESSENTIAL DUTIES AND RESPONSIBILITIES include the following. Other duties may be assigned.

• Manage provider credentialing and recredentialing for licensed staff including therapists, nurses, and other healthcare providers.

• Coordinate payer enrollment and provider applications with Medicaid, Medicare, and commercial insurance companies.

• Perform primary source verification for professional licenses, certifications, education, and training.

• Track and monitor license expirations, certifications, background checks, and credential renewals.

• Maintain accurate provider files in credentialing databases and internal systems.

• Prepare and submit credentialing applications, revalidations, and updates to payers and regulatory agencies.

• Work with HR and program leadership to ensure providers are fully credentialed prior to service delivery.

• Maintain compliance with state licensing boards, healthcare regulations, and payer requirements.

• Assist with audits, compliance reviews, and accreditation documentation. 

• Communicate with providers to collect required documentation and resolve credentialing issues.

• This is a safety sensitive position.

Maintains confidentiality of all information received regarding Friendship Community Care, Inc. and the clients. Conditions of confidentiality shall be in compliance with Friendship Community Care Non-Disclosure Policy and HIPAA Policies.

This job description is not intended to be all inclusive, and employee will also perform other reasonable related business duties as assigned by immediate supervisor and other management as required.

This organization reserves the right to revise or change job duties as the need arises. This job description does not constitute a written or implied contract of employment.

QUALITY ASSURANCE & COMPLAINCE: To adhere to the following and comply with all Quality Assurance’s & HIPAA procedures.

• The Code of Conduct and Compliance Investigation Procedures as read and discussed in the new employee training must be followed at all times.

• Consumers’ progress notes be maintained and completed daily or as needed on the prescribed forms.

• Consumers’ records must be maintained weekly, monthly, quarterly, and yearly. All information must be filed in consumers’ records as needed and updated as prescribed by funding sources.

WORK ENVIRONMENT:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.

EDUCATION and/or EXPERIENCE:

Minimum Qualifications

• Associate’s or Bachelor's degree in Healthcare Administration, Business Administration, Human Resources, or related field preferred. Or equivalent combination of education and experience.
• 1-3 years of healthcare credentialing, provider enrollment, medical staff services, or healthcare administration experience preferred.
• Strong organizational, documentation management, and attention to details skills.
• Proficiency with Microsoft Office and credentialing or HR systems.

Preferred Qualifications

• Experience using credentialing software such as Modio.
• Experience working in behavioral health, developmental disability services, or healthcare organizations.
• Familiarity with state licensing boards and regulatory compliance requirements.

Skills & Competencies

• Provider Credentialing
• Payer Enrollment
• License Verification
• Healthcare Compliance
• Medical Staff Credentialing
• Documentation Management
• Regulatory Compliance
• Time Management & Organization

LANGUAGE SKILLS:

Ability to read, analyze, and interpret general business periodicals, professional journals, technical procedures, or governmental relations. Ability to write reports, business correspondence, and procedure manuals. Ability to effectively present information and respond to questions from groups of employees and managers.

MATHEMATICAL SKILLS:

Ability to calculate figures and amounts such as discounts, interest, commissions, proportions, percentages, area, circumference, and volume. Extensive knowledge of computer software including Window Word, Excel, PowerPoint.

REASONING ABILITY:

Ability to apply commonsense understanding to carry out instructions furnished in written, oral, or diagram form. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

PHYSICAL DEMANDS:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is regularly required to use hands to finger, handle, or feel objects, tools, or controls and talk or hear. The employee frequently is required to stand, walk, and reach with hands and arms. The employee is occasionally required to sit; climb or balance; stoop, kneel, crouch, or crawl; and taste or smell.

The employee must occasionally lift and/or move up to 50 pounds. Specific vision abilities required by this job include close vision, color vision, depth perception, peripheral vision, and the ability to adjust focus.