Credentialing Specialist

Position Summary The Credentialing Specialist is responsible for managing the credentialing and recredentialing processes for healthcare providers to ensure compliance with regulatory, accreditation, and organizational standards. This role verifies provider qualifications, maintains accurate credentialing records, and coordinates with internal departments and external agencies to ensure timely onboarding and ongoing compliance. The Credentialing Specialist plays a critical role in supporting patient safety, regulatory adherence, and operational efficiency across the organization. Essential Duties and Responsibilities Responsible for ensuring that the providers and facilities are fully compliant with all state and federal regulations at all times. Ensure that every provider is legally licensed and/or credentialed and up to date with the latest medical policies and procedures. Create and maintain licensing, credentials and insurance records Conduct research on updated state and federal regulations and policies Release information to requesting agencies and public inquiries when required by law Help develop internal credentialing processes Monitor license and credential expiration dates and advise staff members of required "renew by" dates Ensure the facility and staff members are maintaining compliance with regulatory and accrediting institutions

Verification:

Authenticate provider credentials, including education, training, licensure, and professional references.

Application Management:

Prepare, submit, and track credentialing/recredentialing applications for insurance payers,

Medicaid, and Medicare Data Maintenance:

Update and maintain accurate provider data in databases (e.g., CAQH, Cactus, PECOS).

Compliance & Monitoring:

Monitor license expirations and ensure compliance with state/federal regulations and accreditation standards.

Communication:

Serve as the primary contact for providers, insurance companies, and internal staff regarding status updates. Additional duties as assigned. Minimum Qualifications (Knowledge, Skills, and Abilities) Ability to project a professional Image Proficiency in MS Word, MS Excel, MS Outlook, and credentialing software (e.g., IntelliSoft, Cactus, Vistar) Strong analytical, problem-solving, and critical-thinking skills Advanced knowledge of operating standard office equipment Excellent communication skills - written and verbal Ability to maintain strict confidentiality Ability to manage multiple priorities and work in a fast-paced environment Freedom from use of and effects of use of drugs and alcohol in the workplace Education and/or

Experience:

High school diploma required; Associate's or Bachelor's degree in healthcare administration or related field is preferred Minimum 1-2 years of experience in credentialing, payer enrollment, or a medical staff office setting Familiarity with NCQA, TJC, and CMS regulations Knowledge of SQL or other data querying languages Experience working with cross-functional teams in a technology-driven environment

Certificates, Licenses, Registrations:

Certified Provider Credentialing Specialist (CPCS) designation is highly preferred Physical Demands and Work Environment The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this position. Reasonable accommodation may be made to enable individuals with disabilities to perform the functions. While performing the duties of this position, the employee is regularly required to talk or listen. The employee frequently is required to use hands or fingers, handle or feel objects, tools, or controls. The employee is continually required to stand, walk, sit; and reach with hands and arms. The employee must occasionally lift and/or move up to 25 pounds. The employee may occasionally climb. Specific vision abilities required by this position include close vision, distance vision, and the ability to adjust focus. The noise level in the work environment is usually low to moderate. Occasional travel required.