Credentialing Specialist

About This Role

Coordinating provider credentialing, privileging, and recredentialing activities is the main focus of this role, ensuring compliance with various health regulations and standards. The specialist conducts background investigations, maintains records, monitors licensure, and assists with provider enrollment and revalidation for timely billing readiness.

Responsibilities

• Coordinate the initial appointment, reappointment, recredentialing, and privileging processes for physicians, advanced practice providers, dentists, pharmacists, and other licensed independent practitioners
• Perform primary source verification of education, licensure, certifications, training, work history, malpractice coverage, and other credentialing requirements
• Process credentialing applications in accordance with Medical Staff Bylaws, organizational policies, and accreditation standards
• Query the National Practitioner Data Bank (NPDB), Office of Inspector General (OIG), System for Award Management (SAM), and other required exclusion or sanction databases
• Maintain confidential credentialing files and electronic credentialing databases
• Monitor provider licenses, certifications, DEA registrations, and other required credentials to ensure timely renewal and continued compliance
• Assist with preparation for accreditation surveys and regulatory reviews
• Assist the Revenue Cycle Manager with provider enrollment, revalidation, and maintenance for Medicare, Medicaid, commercial insurance plans, and other third-party payers
• Maintain enrollment records and assist with payer requests for additional documentation
• Monitor enrollment and revalidation deadlines and communicate upcoming requirements to appropriate staff
• Assist with maintaining provider information in CAQH, PECOS, NPPES, and other enrollment systems as applicable
• Coordinate and conduct comprehensive background investigations for employees, contractors, volunteers, students, and other individuals requiring organizational clearance
• Verify criminal history, education, employment history, professional references, licensure, certifications, identity, driving records, and other required screening elements
• Maintain knowledge of applicable accreditation standards, credentialing requirements, and regulatory changes affecting provider credentialing and employment screening
• Assist with policy development and updates related to credentialing and regulatory compliance
• Prepare reports and maintain documentation required for audits, accreditation surveys, and regulatory inspections
• Collaborate with Human Resources, Medical Staff, Revenue Cycle, Compliance, and other departments to support organizational objectives
• Perform other duties as assigned

Requirements

• Associate's degree in Healthcare Administration, Business Administration, Health Information Management, Human Resources, or a related field; or an equivalent combination of education and experience
• Two (2) years of experience in healthcare credentialing, medical staff services, regulatory compliance, human resources, provider enrollment support, or a related administrative healthcare role
• Strong organizational skills with the ability to manage multiple priorities and meet deadlines
• Proficiency with Microsoft Office and electronic database systems
• Ability to maintain strict confidentiality and exercise sound judgment when handling sensitive information
• Excellent written and verbal communication skills

Nice to have:

• Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, Public Administration, or a related field
• Experience with provider credentialing and privileging in an ambulatory healthcare organization, tribal health program, or hospital
• Experience supporting provider enrollment with Medicare, Medicaid, commercial insurance plans, and other third-party payers
• Experience using credentialing and enrollment systems such as CAQH, PECOS, NPPES, or similar platforms
• Familiarity with AAAHC accreditation standards, Indian Health Service operations, and Tribal Self-Governance programs
• Certification such as Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM), or the ability to obtain certification within two years of hire
• Knowledge of federal exclusion databases, provider licensing requirements, and healthcare regulatory compliance

Important Details

• Employment offers are contingent upon the satisfactory completion of a background check and pre-employment drug test
• Successful applicants are subject to a 60 business day probationary period

About the Company

Rocky Boy Health Center is committed to ensuring compliance with Medical Staff Bylaws, accreditation standards, payer requirements, and applicable federal, state, and tribal regulations.