Credentialing Specialist
2 days ago
Position Summary:
The Credentialing Specialist is responsible for ensuring healthcare providers meet all necessary licensing, certification, and regulatory requirements. This role involves verifying credentials, maintaining compliance with industry standards, and managing provider enrollment with insurance payers. The Credentialing Specialist plays a critical role in supporting healthcare operations by ensuring providers can legally and efficiently offer services.
Job Details:
Work from Home
Monday to Friday | 8 AM to 5 PM EST (8:00 PM to 5:00 AM PST)
Following Select US Holidays (Christmas, New Year, Thanksgiving, Independence Day, Labor Day)
Responsibilities:
- Provider Credentialing & Verification
- Collect and review provider applications, licenses, certifications, and other credentials.
- Verify educational background, training, work history, and references.
- Confirm board certifications, malpractice insurance, and compliance with state and federal regulations.
- Process applications for enrollment with Medicare, Medicaid, and commercial insurance payers.
- Track and maintain credentialing and re-credentialing deadlines to ensure timely renewals.
- Ensure compliance with industry standards (e.g., NCQA, JCAHO, CMS, and state medical boards).
- Maintain accurate provider records in credentialing databases and tracking systems.
- Update and manage records for licensure, certifications, and payer enrollment.
- Generate reports and track status updates for credentialing and re-credentialing processes.
- Serve as the primary point of contact for providers, insurance companies, and regulatory agencies regarding credentialing matters.
- Collaborate with internal teams, including human resources, billing, and compliance, to facilitate provider onboarding and payer enrollment.
- Address and resolve credentialing issues that may delay provider enrollment or reimbursement.
- Conduct periodic audits of credentialing files to ensure accuracy and compliance.
- Monitor changes in credentialing regulations and industry requirements.
- Implement best practices to enhance efficiency in the credentialing process.
Required Qualifications & Skills
- Education: High school diploma or GED required; associate's or bachelor's degree in healthcare administration, business, or a related field preferred.
- Experience: Minimum of 1-3 years of credentialing experience in a healthcare or insurance setting.
- Technical Skills:
- Proficiency in credentialing software and provider enrollment portals.
- Strong knowledge of state and federal credentialing requirements.
- Familiarity with CAQH, PECOS, NPPES, and payer enrollment processes.
- Soft Skills:
- Excellent attention to detail and organizational skills.
- Strong problem-solving and critical-thinking abilities.
- Effective communication and interpersonal skills.
- Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
Preferred Qualifications
- Certified Provider Credentialing Specialist (CPCS) or Certified Professional in Medical Services Management (CPMSM) certification.
- Experience working in a hospital, medical group, or managed care organization.
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