About This Role
The Credentialing Specialist ensures all healthcare professionals within the organization are properly credentialed and compliant with state, federal, and organizational regulations. This role involves verifying qualifications, maintaining accurate records, and ensuring timely re-credentialing, playing a crucial part in supporting the overall quality of care.
Responsibilities
- Conducts primary source verifications of licensure, board certifications, education, and work history
- Tracks and manages re-credentialing timelines to ensure timely renewal and compliance
- Maintains and updates credentialing databases and records with accuracy and confidentiality
- Communicates with providers and internal departments regarding credentialing status and documentation needs
- Collaborates with compliance and quality teams to ensure adherence to standards (e.g., NCQA, CMS, The Joint Commission)
- Responds to credentialing-related inquiries and audit requests
- Assists in preparing files for credentialing committee review and maintain records of decisions
Requirements
- Associate degree (AA/AS) in healthcare administration, business, or a related field and 2 or more years of relevant experience required; or equivalent combination of education and experience to include:
- Minimum of 2 years of experience in credentialing within a healthcare or managed care setting
- Working knowledge of credentialing standards and regulatory bodies such as NCQA, CMS, and The Joint Commission
- Experience using credentialing databases or platforms such as CAQH, Verity, or MD-Staff
- Proficiency in Microsoft Office applications including Excel, Outlook, and Word
- Strong organizational, analytical, and interpersonal skills
- Ability to handle sensitive data with discretion and confidentiality
- Willingness to obtain Certified Provider Credentialing Specialist (CPCS) certification within 1-2 years if not already held
- Demonstrates strong attention to detail and accuracy
- Maintains confidentiality and exercises discretion with sensitive information
- Manages time effectively and meets strict deadlines
- Communicates clearly, professionally, and respectfully
- Applies sound judgment when resolving issues or discrepancies
- Works independently while also contributing to team goals
- Adapts to changing priorities and processes with flexibility
- Maintains a high level of reliability and accountability
- Builds positive relationships with internal staff and external providers
- Physical Requirements: The employee may be required to use hands to handle or feel objects, tools or controls; reach with hands and arms; and taste or smell. Specific vision abilities required by the job include close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.
