About This Role
This Credentialing Specialist role involves processing initial and recredentialing applications for individual providers, assisting with clinical staff onboarding, and ensuring compliance with various regulatory requirements. The position is crucial for maintaining accurate credentialing databases and facilitating insurance enrollment for eligible staff.
Responsibilities
- Process individual provider initial credentialing applications and biennial recredentialing applications
- Assist in onboarding clinical staff by verifying credentials, identity, degrees, certification, work history, etc.
- Monitor electronic credentialing workflow
- Evaluate the quality of information provided by the CVO and escalate exceptions to the Clinical Director for review
- Ensure each individual credentialing application is processed by the credentialing committee for all initial and recredentialed clinical staff
- Monitor State Professional Licensure, Board Certification, DEA, CDS, and other credentials as required
- Review for pending expiration dates and follow up with staff to ensure their compliance
- Review CredentialStream alerts for State exclusions and professional licensing sanctions, OIG exclusions, SAM exclusions, Federal Sanctions, and notify the Clinical Director of all identified concerns
- Maintain database of credentialed staff in CredentialStream, which includes staff credentials and insurance eligibility
- Prepare payer rosters and delegate credentialing oversite reports using the cadence defined by each insurance company
- Enroll and empanel eligible clinical staff as determined by insurance contracts
Requirements
- High school diploma or GED required
- Knowledge of insurance, clinical license levels and educational degrees, CPT coding, and guarantor credentialing standard required
- Familiarity with PECOS, NPI, CAQH, OIG exclusion list, and Med Advantage required
- Insurance background with coding and billing required
Benefits
- Purpose-driven work – make a meaningful impact in the lives of individuals, families, and communities throughout Western Massachusetts
- Professional growth – access ongoing training, mentorship, career development, and advancement opportunities across one of the region's largest behavioral health organizations
- Supportive team culture – join a collaborative workplace guided by our HEART values: Humanity, Empowerment, Accountability, Respect, and Teamwork
- Stability and opportunity – build your career with a well-established organization serving Western Massachusetts since 1938
- Comprehensive benefits – generous PTO, 403(b), educational assistance, medical, dental, vision, employee assistance programs, and more
