Credentialing Specialist

Title:                      Credentialing Specialist

Overall Responsibilities:


Responsible for entering, processing and maintaining the accuracy and integrity of the enrollment, credentialing and re-credentialing of Providers and PRI facilities with third party payers. Maintains a working knowledge of requirements of Center of Medicaid/Medicare Services (“CMS”), National Committee for Quality Assurance (“NCQA”) and 3rd party insurance requirements. This position maintains a high level of confidentiality, attention to detail, & professionalism and for credentialing and preparing clinicians for billable services.


Under the supervision of the Director of Healthcare Operations, Planning, and Policy, the Credentialing Specialist performs tasks necessary to ensure timely, accurate and reliable processing of healthcare services staff appointments, reappointments and managed care enrollment, delegated credentialing and re-credentialing and managed care audits


Essential Duties and Responsibilities:

The essential duties of the Credentialing Specialist include but are not limited to the following activities:

·         Responsible for all Credentialing processes related to compliance, regulations and billable services

·         Provide initial and reappointment applications to providers

·         Review application packages for and interact with providers and department leadership, including verify provider identification, education, training, certifications, professional affiliations, licensing, claims history and work history

·         Search databases for medical malpractice claims and for Medicare/Medicaid and other sanctions.

·         Assemble peer review letters, proof of continuing education, health clearance

·         Maintain accurate department database for providers

·         Provide updated information to managed care companies to support the organization’s delegated credentialing status

·         Prepare for and handle audits by managed care companies.

·         Provide credentialing verification to other institutions upon request and release from current or past medical staff members

·         Provides routine reports to physicians and support staff regarding the status of participation in insurance plans

·         Provides updates regarding managed care plan credentialing procedure changes and other relevant information

·         Produces management reports regarding operations performance and/or provider credentialing status for internal management and external providers using the organization’s verification services.

·         Adheres to operating policies and procedures including delivery of completed work and use of resources.

·         Initiates correspondence to providers, users, health plans and others as necessary to obtain requisite credentialing information

·         Informs management regarding the status of departmental operations and provider credentialing issues of concern

·         Additional tasks as needed and directed



·         Bachelor’s degree required

·         Minimum of two (2) years of credentialing experience in a hospital/community health center setting

·         Must be proficient with PECOS, CAQH, NPPES as well as the credentialing and re-credentialing process

·         Computer database skills and word-processing, required. Familiarity with Microsoft Office applications, desirable.

·         Excellent time management, organizational, and customer service skills.

·         High degree of organizational skills

·         Excellent written and verbal communication skills.

·         Capable of building strong customer relationships and delivering customer-centric service to internal/external colleagues and candidates for appointment

·         A good decision-maker, with proven success at making timely decisions that keep the organization moving forward

·         Adept at planning and prioritizing work to meet deadlines in a fast-paced environment

·         Consistently achieving results, even under time sensitive conditions

·         An effective communicator, capable of determining how best to reach different audiences and executing communications based on that understanding

·         Certified Provider Credentialing Specialist (CPCS) certification preferred


To apply: E-mail resume and cover letter indicating position and salary requirements to: