Credentialing Specialist

What You'll Do

• Verification: Conduct primary source verification of provider education, training, work history, licenses, and board certifications.
• Processing: Review, validate, and process initial and re-credentialing applications for providers and insurance payers and networks in an accurate and timely manner. Ensure appropriate and timely provider and payer notifications.
• Payer Enrollment: Submit and track provider enrollment applications with Medicare, Medicaid, and commercial insurance plans and networks.
• Tracking & Compliance: Monitor license and certification expiration dates, manage renewals, and maintain strict compliance with guidelines from NCQA or HHS/CMS. Develop knowledge of insurance carriers and requirements.
• Database Management: Keep digital records and profiles accurate in internal systems and platforms like CAQH ProView. 
• Communication: Serve as the main point of contact for providers, insurance payers, and internal teams regarding credentialing and payer enrollment statuses. Establish and maintain relationships with insurance providers and credential personnel.
• Other: Interact with other administrative departments, senior management and Director of Revenue Cycle. Perform other duties as assigned.

What We’re Looking For

• Education: High school diploma or GED required. An Associate or Bachelor degree in Healthcare Administration or a related field is preferred.
• Experience: 1 to 3 years of background in healthcare administration, provider credentialing, or payer relations.
• Certifications: CPCS (Certified Provider Credentialing Specialist) or CPES (Certified Payer Enrollment Specialist) designation is a plus.
• Skills: Exceptional attention to detail, strong problem-solving and decision-making capabilities, outstanding time management and organizational skills, effective written and verbal communication, and the ability to maintain confidentiality with sensitive data.