Credentialing Specialist

Mission of Department:

We are looking for a Credentialing Specialist to join our dynamic team. In this role, you will support the credentialing process for healthcare professionals, ensuring compliance with regulations and facilitating timely onboarding. This position is essential to maintaining our high standards for quality and safety in patient care.

Purpose of Position:

The Credentialing Specialist is responsible for ensuring that all healthcare providers are properly credentialed, enrolled, and compliant with hospital, state, and payer requirements. This position manages the complete credentialing, recredentialing, and payer enrollment processes for medical staff and allied health professionals, ensuring timely and accurate completion of all related documentation and verifications.

Essential Functions:

· Process initial appointments, reappointments, and privilege applications for physicians and allied health professionals in accordance with medical staff bylaws and regulatory standards (TJC, NCQA, CMS, state/federal). 

· Verify provider credentials including education, training, licensure, certifications, malpractice history, work history, and references. 

· Maintain provider data in credentialing databases and electronic files. 

· Coordinate credentialing committee and medical executive committee reviews; prepare and distribute meeting materials. 

· Communicate credentialing status updates to department chairs, providers, and leadership. 

· Ensure timely recredentialing to maintain compliance.

Payor Credentialing and Enrollment

· Prepare and submit enrollment applications for commercial, Medicare, and Medicaid payers.

· Track application status and follow up with payers to ensure timely approval.

· Maintain accurate provider enrollment records and payer IDs.

· Manage CAQH profiles, including reattestations and updates.

· Collaborate with billing and revenue cycle teams to resolve payer enrollment issues.

Additional Responsibilities:

· Assist in collecting and verifying credentialing documents from providers. 

· Support application reviews to ensure compliance with regulations. 

· Participate in audits and quality improvement initiatives; prepare reports as needed. 

· Stay current with changes in healthcare regulations, credentialing standards, and payer policies. 

· Maintain confidentiality of provider and organizational information in compliance with HIPAA.

The preceding functions have been provided as examples of the types of work performed by employees assigned in this job classification. Management reserves the right to add, modify, change or rescind work assignments and to make reasonable accommodations as needed. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed above are representative of the knowledge, skills and /or abilities required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. 

Requirements

Education, Qualifications, Experience:

· High School Diploma or Equivalent

· 2–4 years of credentialing experience preferred, including both medical staff and payer credentialing. 

· Experience with hospital medical staff services and provider enrollment systems (e.g., CAQH, Availity, PECOS). 

· Will train the right candidate with strong foundational skills. 

· Training may be provided for the ideal candidate. 

Preferred Qualifications:

· Associate's degree in healthcare administration or related field, or equivalent experience

· Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Staff Management (CPMSM) through NAMSS.

Personal Characteristics:

· High ethical values, honest and reliable. 

· Superior interpersonal abilities. Ability to have a good relationship with diverse personalities, tactful, mature, flexible.

· Exceptional written and verbal communication skills.

· Resourceful, well organized, and goal driven.

· Ability to establish credibility and be decisive while recognizing and supporting the organization's preferences and priorities.

· Service oriented.

Knowledge, Skills, and Abilities:

· Proficiency in Microsoft Office Suite. 

· Experience with credentialing software and electronic health records (EHR). 

· Strong data entry and database management skills. 

· Basic understanding of healthcare regulations and standards.

· Strong attention to detail, accuracy, and organizational skills. 

· Excellent verbal and written communication. 

· Ability to manage multiple tasks and meet deadlines. 

· Initiative-taking problem-solving and process improvement mindset. 

· Ability to work independently and collaboratively. 

· Commitment to confidentiality and professional integrity.

Equipment: 

Computer, Scanner, Copier, Printer, and 10 key competency.

Expectation of Service: This is a non-exempt 40 hour per week position. Regular and punctual attendance is required. 

Physical Requirements: This sedentary position requires sitting most of the time at a desk and typing at a computer terminal. There is potential for repetitive motion of hand and wrist with these tasks. There is possibility of eye strain when working on the computer for long periods of time. Requires walking, standing, bending and stooping some of the time. Requires hearing and vision, with or without correction that is adequate for all types of interpersonal communications. This list is not exhaustive and may be supplemented.