Credentialing Specialist (2026)

Native Preference in hiring is given to qualified enrolled members of Paskenta Band of Nomlaki Indians and Native Americans in accordance with the Band’s Preference Policy, Chapter 1-715 of the Paskenta Band of Nomlaki Indians Tribal Policies). Applicants claiming Indian Preference must submit verification of Indian certified by tribe of affiliation or other acceptable documentation of Indian heritage.

The Credentialing Specialist is responsible for facilitating requests for initial appointment, clinical privileges, re-appointment, and annual review in compliance with HRSA, CMS, Indian Health Services (IHS), health plan policies, Medical Staff Bylaws, NCQA Accreditation Standards, FTCA requirements, and federal and state regulations. This role also manages payer enrollment and revalidation processes for both individual providers and the organization’s facilities, including CMS forms 855I, 855B, and 855A. The Credentialing Specialist serves as a key liaison between clinical leadership, Human Resources, and operational departments to ensure timely and compliant onboarding, enrollment, and privileging of providers across all payer types.

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• Conduct primary source verification and data collection for all medical staff and clinical privilege applicants, including reappointments, per all regulatory requirements and timelines.

• Advise medical staff leadership of potential issues, investigate as required, and escalate major concerns to the Manager.

• Establish and maintain credential files in an organized and compliant manner for all assigned Practitioners, OLCPs, and clinical staff.

• Facilitate review and approval of completed credentialing files with prior to submission to the Governing Board.

• Maintain strict confidentiality throughout the credentialing and privileging process.

• Enter new applications and updates into credentialing software and maintain current file status records.

• Assist Patient Accounts with Medicare/Medicaid enrollment, revalidation, and related changes.

• Produce monthly reports on upcoming licensure and immunization renewals for managers.

• Monitor provider profiles in CAQH, PECOS, PAVE and NPPES to ensure consistency across systems. Coordinate NPPES updates with the Compliance or Administrative team as needed.

• Complete required credentialing, re-credentialing, and privileging applications for provider enrollment in commercial payers, Medicare, and Medicaid.

• Coordinate and submit enrollment applications for Medicare (PECOS), Medi-Cal (PAVE), and commercial payers for all new providers and locations.

• Manage timely revalidations and updates across all payers, including tracking of submission deadlines and confirmations.

• Complete and maintain CMS enrollment forms, including CMS 855A, 855I, and 855B, ensuring accuracy and alignment with Tribal and FQHC scope of services.

• Monitor and update provider and facility enrollment status across PECOS, NPPES, CAQH, and other relevant databases.

• Serve as a liaison with CMS and state Medicaid agencies regarding enrollment discrepancies or follow-up.

• Oversee CMS facility revalidation processes, including timely submission of documentation to maintain active Medicare enrollment for the organization. Coordinate with leadership to address any changes in ownership, service location, or compliance scope.

• Collaborate with Billing staff to resolve authorization and denial issues.

• Maintain individual provider files with updated information for necessary credentialing applications.

• Fluent knowledge of medical terminology.

• Ability to communicate professionally and handle multiple tasks simultaneously.

• Ability to work independently and exercise appropriate discretion.

• Ability to maintain confidentiality.

• Advanced proficiency in MS Office Suite.

• General understanding of finance and accounting policies and terminology.

• Strong interpersonal, written, and verbal communication skills.

• Excellent editing, grammar, and punctuation skills.

• High attention to detail and strong organizational skills.

• Knowledge of Rolling Hills Clinic structure, standards, procedures, and protocols.

• Ability to relate and communicate effectively with community interest groups, agencies, and American Indian-serving medical facilities.

• Perform other duties as assigned.

Background Check Requirements:

Pre-employment Drug Testing and a Department of Justice Fingerprinting clearance through Federal, State and Child Abuse Index is a contingency for an offer of employment. Criminal clearances are obtained to protect the welfare and safety of clients receiving services at Rolling Hills Clinic.

Vaccination Requirements:

Provide vaccination records to show proof of immunity for TB, Measles, Mumps, Rubella, Varicella, TDAP & Hep B. If the records are more than 10 years old, titers are required to confirm immunity.

"Native Preference in hiring is given to qualified enrolled members of Paskenta Band of Nomlaki Indians and Native Americans in

accordance with the Band’s Preference Policy (Chapter 1-715 of the Paskenta Band of Nomlaki Indians Tribal Policies).

Applicants claiming Indian Preference must submit verification of Indian certified by tribe of affiliation or other acceptable

documentation of Indian heritage.”

Employment with Rolling Hills Clinic is voluntarily entered into. All RHC personnel are employed on an at-will basis. At-will employment may be terminated with or without cause, and with or without notice at any time by the employee or by RHC. No manager, supervisor, or employee of the organization has any authority to enter into an agreement for employment for any specified period of time or to make an agreement for employment other than at-will terms. The job description does not constitute an employment agreement between Rolling Hills Clinic and employee and is subject to change by the Paskenta Band of Nomlaki Indians.