Credentialing Specialist

Position Summary

We are seeking a detail-oriented and highly organized Credentialing Specialist to support the verification, enrollment, and ongoing compliance of healthcare providers. This role is critical to ensuring providers are properly credentialed, appointed, and privileged with payers, hospitals, and patient care facilities, enabling timely reimbursement and regulatory compliance.

The ideal candidate has hands-on experience with provider credentialing and re-credentialing, primary source verification (PSV), and managing provider data across multiple systems in a fast-paced healthcare environment.

Key Responsibilities

Provider Credentialing & Enrollment

• Collect, review, and process initial and re-credentialing applications for healthcare providers.
• Ensure applications are complete, accurate, and submitted within required payer and regulatory timelines.
• Serve as a primary point of contact for providers regarding credentialing requirements, status updates, and follow-up items.
• Track application progress and proactively follow up with providers, payers, hospitals, and facilities.

Primary Source Verification (PSV)

• Perform and document primary source verification for provider credentials, including:
• State professional licenses
• DEA registrations
• Board certifications
• Education and training
• Work history
• Sanctions and exclusions (OIG, SAM, NPDB, CMS Preclusion List, etc.)
• Ensure all verification activities meet federal, state, payer, and accreditation standards.

Credentialing, Appointment & Privileging

• Complete credentialing, re-credentialing, and privileging processes to ensure providers are credentialed and appointed with:
• Health plans and payers
• Hospitals and health systems
• Patient care facilities and networks
• Prepare credentialing files for review by Credentialing Committees, as applicable.
• Issue approval, denial, or deficiency communications in accordance with established policies.

Compliance & Quality Assurance

• Ensure compliance with federal and state regulations, payer requirements, and accreditation standards (e.g., NCQA, CMS).
• Maintain knowledge of current health plan and agency credentialing requirements.
• Adhere to internal policies, procedures, and delegated credentialing agreements.

Data Management & Reporting

• Maintain accurate and up-to-date provider records in credentialing databases and online systems.
• Track license, certification, DEA, and malpractice insurance expirations and ensure timely renewals.
• Prepare reports related to credentialing activity, provider rosters, accreditation, and privileging status.

Documentation & File Maintenance

• Maintain complete credentialing files, including copies of:
• Current state licenses
• DEA certificates
• Malpractice insurance coverage
• Board certifications and other required documentation
• Maintain corporate provider contract files aligned with credentialing records.
• Ensure confidentiality and security of all credentialing information.

Qualifications

Required

• High school diploma or equivalent.
• 5-7 years of experience in provider credentialing, provider enrollment, or healthcare administration.
• Strong knowledge of credentialing processes and primary source verification.
• Experience working with health plans, hospitals, and provider networks.
• Proficiency with credentialing software, databases, and online verification systems.
• Excellent attention to detail, organization, and time management skills.
• Strong written and verbal communication skills.

Preferred

• Associate’s or Bachelor’s degree in healthcare administration, business, or a related field.
• Experience with delegated credentialing programs.
• Familiarity with NCQA standards and CMS requirements.
• Credentialing certification (CPCS, CPMSM, or equivalent).

What We Offer

• • Competitive compensation
  • Comprehensive benefits package
  • Supportive, collaborative team environment
  • Opportunity to work in a mission-driven healthcare organization
  • Professional growth and development opportunities