Credentialing Specialist
1 week ago
Key Responsibilities:
- Primary Source Verification: Meticulously verify provider credentials, including licenses, certifications, degrees, and training, by contacting the original sources (e.g., state licensing boards, medical schools, residency programs).
- Application Management: Compile and process initial credentialing and re-credentialing applications for various payers, including Medicare, Medicaid, and commercial insurance plans.
- Database Maintenance: Accurately enter and maintain all provider information in a credentialing database or software (e.g., CAQH), ensuring all data is up-to-date and easily accessible for audits.
- Compliance and Expiration Tracking: Proactively monitor and track the expiration dates of provider licenses, certifications, and malpractice insurance to ensure timely renewals and continuous compliance.
- Communication: Serve as a primary point of contact for providers, medical staff, and insurance companies to resolve discrepancies, follow up on pending applications, and communicate status updates.
- Audits and Reporting: Prepare and submit documentation for internal and external audits by regulatory and accrediting bodies like NCQA or The Joint Commission.
Job Qualifications and Skills:
- Education: A high school diploma is required, with an Associate's or Bachelor's degree in healthcare administration or a related field being preferred.
- Experience: A minimum of 1 year of experience in healthcare administration, medical billing, or a credentialing role is typically required.
- Technical Skills: Proficiency with credentialing software (e.g., CAQH, Credential Stream), electronic health records (EHR), and Microsoft Office Suite is essential.
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