Credentialing Specialist

Essential Duties and Responsibilities

• Manage the credentialing and recredentialing process for physicians, nurse practitioners, physician assistants, nurses, behavioral health professionals, and other healthcare providers.
• Prepare, submit, and track initial credentialing and recredentialing applications with commercial insurance companies, Medicare, Medicaid, and other government or third-party payers.
• Verify provider credentials, including licenses, certifications, education, training, work history, malpractice coverage, DEA registration, NPI, and other required documentation.
• Maintain accurate and up-to-date provider credentialing files and databases.
• Conduct primary source verification in accordance with organizational and regulatory requirements.
• Monitor provider licenses, certifications, registrations, malpractice insurance, and other expirable credentials.
• Track application status and follow up with payers, healthcare organizations, and providers to resolve outstanding items.
• Assist with provider enrollment, payer participation, and demographic updates.
• Complete and maintain CAQH profiles and ensure information remains current and accurate.
• Identify missing, incomplete, or inconsistent information and work with providers to obtain required documentation.
• Process provider additions, terminations, demographic changes, practice location changes, and payer updates.
• Maintain credentialing spreadsheets, reports, and tracking systems.
• Ensure all credentialing activities are completed within established deadlines.
• Communicate professionally with providers, payer representatives, healthcare organizations, and internal departments.
• Assist with audits and provide credentialing documentation as requested.
• Maintain compliance with HIPAA, payer requirements, organizational policies, and applicable federal and state regulations.
• Maintain strict confidentiality of provider and organizational information.
• Prepare regular reports regarding credentialing status, pending applications, expirables, and enrollment activities.
• Participate in process-improvement initiatives to improve the efficiency and accuracy of the credentialing process.
• Perform other duties as assigned.

Qualifications

• High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business administration, or a related field preferred.
• 2 years of experience in healthcare credentialing, provider enrollment, medical staff services, or a related healthcare administrative role preferred.
• Knowledge of commercial and government payer credentialing and enrollment processes.
• Familiarity with CAQH, NPI, Medicare, Medicaid, PECOS, and payer portals preferred.
• Strong understanding of provider licensing and credentialing requirements.
• Excellent organizational and time-management skills.