Credentialing Specialist

Credentialing Specialist Job Description

Position Summary

The Medical Practice Credentialing Specialist is responsible for coordinating and maintaining the credentialing and recredentialing processes for physicians and advanced practice providers. This role ensures compliance with federal and state regulations, accreditation standards, payer requirements, and organizational policies. The specialist works closely with providers, insurance payers, medical staff offices, and regulatory agencies to maintain accurate provider records and timely enrollment.

Essential Duties & Responsibilities

·        Manage the credentialing and recredentialing process for physicians and advanced practice providers.

·        Prepare, submit, and track provider applications for health plans, hospitals, and applicable healthcare organizations.

·        Validate and maintain provider credentials, including:

o   Medical licenses

o   DEA registrations

o   Board certifications

o   Education and training

o   Work history

o   Malpractice insurance coverage

o   NPDB (National Practitioner Data Bank) reports

·        Maintain provider files and credentialing databases (CAQH).

·        Monitor expiration dates and ensure timely renewals of licenses, certifications, and insurance.

·        Coordinate provider enrollment and revalidation with Medicare, Medicaid, and commercial insurance carriers.

·        Respond to payer requests and resolve credentialing matters.

·        Prepare reports for leadership regarding credentialing status and compliance metrics.

·        Maintain confidentiality and HIPAA compliance in all credentialing activities.

·        Assist with audits and accreditation reviews.

Qualifications

Education

·        High School Diploma or GED required.

·        Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or related field preferred.

Experience

·        1–3 years of credentialing, provider enrollment, medical staff services, or healthcare administration experience preferred.

Certifications (Preferred)

·        Certified Provider Credentialing Specialist (CPCS)

·        Certified Professional Medical Services Management (CPMSM)

Knowledge, Skills & Abilities

·        Knowledge of provider credentialing and payer enrollment processes.

·        Familiarity with Medicare, Medicaid, and commercial payer requirements.

·        Strong attention to detail and organizational skills.

·        Excellent written and verbal communication skills.

·        Proficiency in CAQH, credentialing software, databases, and Microsoft Office Suite.

·        Ability to manage multiple deadlines and prioritize work effectively.