Credentialing Specialist

Job Summary:

The Credentialing Specialist is responsible for independently managing the end-to-end provider credentialing, re-credentialing, and privileging process for physicians, advanced practice providers, and clinical staff. This role ensures providers maintain active enrollment with commercial payers, Medicare, Medicaid, hospitals, and healthcare facilities while maintaining accurate provider records across credentialing systems.

Job Description:

• Manage the complete credentialing, re-credentialing, and privileging lifecycle for healthcare providers.

• Process provider enrollments with commercial insurance payers, Medicare, Medicaid, hospitals, and healthcare facilities.

• Maintain provider records, credentialing files, and documentation required for regulatory compliance.

• Perform Primary Source Verification (PSV) and monitor provider eligibility through NPDB, OIG/GSA-SAM, state licensing boards, and other verification sources.

• Maintain provider profiles within CAQH, PECOS, NPPES, CMS, and other credentialing platforms.

• Process provider license renewals including professional licenses, DEA registrations, and Controlled Substance registrations.

• Complete payer revalidation requests and credentialing applications.

• Partner with billing teams to resolve credentialing-related claim denials and authorization issues.

• Maintain audit-ready documentation and support internal and external compliance audits.

• Prepare credentialing reports and provider documentation for leadership and credentialing committees.

Qualifications:

• Demonstrates knowledge and understanding of the credentialing, re-credentialing, and privileging processes (PSV, NPDB, CAQH, PECOS, NPPES, payer enrollment).

• Demonstrates strong attention to detail and documentation accuracy.

• Proven ability to organize and prioritize work and manage multiple priorities and deadlines independently.

• Proven ability to research and analyze data.

• Proven ability to work independently with minimal supervision.

• Proven ability to establish and maintain effective working relationships with providers, management, staff, and contacts outside the organization.

• Clear and coherent both written and verbal communication skills in English.

Screening Criteria:

• Bachelor's Degree in Healthcare Administration, Nursing, Medical Technology, Public Health, Health Services, or a related healthcare field.

• Minimum of three (3) years of healthcare provider credentialing experience.

• Experience in Microsoft Office applications (Word, Excel) and internet resources.

• Must have stable employment history.