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
