Credentialing Specialist

Overview

The Credentialing Specialist plays a critical role in the growth and development of a small, dynamic, and expanding nonprofit health plan. As the organization is currently undergoing a reorganization with a startup atmosphere, this position offers an exciting opportunity to contribute to building essential credentialing processes while ensuring compliance with Sendero policies and industry regulations. The Credentialing Specialist will manage the credentialing and re-credentialing activities for all providers, collaborating closely with various departments to support the organization’s growth trajectory. This is an ideal position for a self-motivated, adaptable individual who thrives in a fast-paced, evolving environment.

Responsibilities

Essential Functions:

• Coordinate and maintain the credentialing and re-credentialing process for all Sendero providers including ancillary and facility providers, ensuring timely and accurate completion of applications and compliant with policies and regulatory standards.
• Process, update and maintain provider files, review and load data into the credential database ensuring that all applications and licensure information are current while maintaining high quality standards.
• Obtain primary source verification of education, licensure, work experience, and other relevant qualifications through appropriate verification agencies.
• Ensure compliance with regulatory standards, including TDI, NCQA, CMS, and other pertinent agencies during the credentialing process.
• Assist with regulatory audits, ensuring that credentialing documentation meets the necessary requirements.
• Participate in the implementation and conversion of new credentialing software.
• Assist in developing configuration standards and best practices for credentialing systems, identifying opportunities for process improvements to enhance efficiency and quality.
• Assist the network team with tasks related to credentialing and provider management.
• Perform other duties as assigned and required by management, recognizing that job responsibilities may evolve as directed

Knowledge, Skills and Abilities:

• The ability to thrive in an environment of change, adjust quickly to shifting priorities and new challenges as the organization grows and evolves
• Proficient in the use of computer systems specifically Microsoft office, Adobe, and experience with credentialing software
• Detail-oriented with strong organizational and communication skills
• Ability to work independently and as part of a team to support cross-functional efforts.
• Strong understanding of credentialing and re-credentialing processes, including provider applications, licensure verification, and primary source verification.
• Open to continuous learning and self-improvement, embracing new tools, systems, and industry trends that can support the organization's growth.
• Maintaining a positive attitude and staying focused under pressure, especially when dealing with tight deadlines or unexpected roadblocks.

Qualifications

Required: High School Diploma or equivalent (higher degree accepted)

Required: 2 years credentialing in healthcare setting