Credentialing Specialist

About This Role

This full-time position works with the Revenue Cycle Team at the corporate office in Plano, TX. The role involves managing provider credentialing processes, ensuring compliance with regulations, and maintaining accurate provider data for a growing network of psychiatric practices.

Responsibilities

• Compile and maintain current and accurate data for all providers
• Enter and maintain provider information in online credentialing databases and systems (Credential My Doc, CAQH, PECOS, NPPES, and SharePoint)
• Perform primary source verification of State license, DEA, and Board certification
• Complete provider initial and re-credentialing applications
• Audit applications for accuracy and completeness
• Handle revalidation requests issued by all payers
• Submit completed credentialing applications and supporting documentation to all requested payers
• Monitor application progress and follow up with payers as needed until confirmation of "in network" status has been received
• Maintain copies of current state licenses, DEA certificates, malpractice coverage, and any other required credentialing documents for all providers
• Track all state license, DEA, and board certification expirations for all providers to ensure timely renewals
• Track CME and send quarterly updates to providers
• Utilize strong research skills to gather pertinent information regarding providers
• Maintain billing insurance grid, provider insurance grid, and each physician’s spreadsheet up to date on current insurance changes
• Maintain practitioner electronic file by keeping all applications/licensures current
• Collect and validate documents to ensure accuracy of all credentialing elements
• Assist in training and monitoring of credentialing specialists, assign work, and review for accuracy
• Assist in streamlining credentialing process, onboarding, and offboarding for providers and new centers
• Escalate any personnel issues to Credentialing Supervisor
• Report and/or escalate provider enrollment issues to RCM leadership

Requirements

• Bachelor's degree in healthcare administration, business administration, or a related field preferred
• Minimum of 3 years of experience in provider enrollment and credentialing
• Extensive knowledge of provider enrollment regulations and guidelines, including Medicare, Medicaid, and commercial payer requirements
• Strong understanding of credentialing processes and best practices
• Experience with various payer enrollment portals and systems
• Excellent communication, interpersonal, and organizational skills
• Ability to manage multiple projects simultaneously and meet deadlines