Credentialing Specialist

POSITION SUMMARY

The Credentialing Specialist manages the initial credentialing, re-credentialing, and payer enrollment process for the practice’s surgeons and other licensed providers in conjunction with the TPA. This position ensures providers maintain active, unrestricted privileges at all facilities where they perform surgery and remain properly enrolled with commercial and government payers, protecting the practice’s ability to bill for services without interruption. The role works closely with providers, the Practice Administrator, hospital and ambulatory surgery center medical staff offices, the TPA and payer representatives, exercising independent judgment to track deadlines, resolve discrepancies, and maintain compliant, audit-ready credentialing files. Errors or delays in this role can directly disrupt provider privileges, surgical scheduling, and claims reimbursement.

ESSENTIAL FUNCTIONS

• Manages initial credentialing and recredentialing applications for surgeons and other providers with hospitals, ambulatory surgery centers, and health plans, ensuring accurate, ontime submission in conjunction with the TPA.
• Completes and submits provider enrollment applications for commercial payers; tracks application status and supports the follow up with the TPA to resolve delays or deficiencies.
• Reviews provider credentialing files and databases (including CAQH and payer portals), tracking license, DEA, board certification, and insurance expirations and initiating timely renewals in conjunction with the TPA.
• Coordinates with hospital and ambulatory surgery center medical staff offices on privileging, reappointment, and OPPE/FPPE requirements to maintain continuous provider privileges in conjunction with the TPA.
• Prepares credentialing status reports for the Practice Administrator and providers, and escalates expiring credentials or atrisk enrollments before they lapse using the TPA platform.
• Maintains regular and reliable attendance sufficient to meet the position’s operational, patientservice, and team obligations, with or without reasonable accommodation.
• Complies with applicable laws, regulations, accreditation requirements, privacy and security standards, and organizational policies relevant to the position.

The essential functions listed are intended to describe the fundamental duties of the position. A qualified individual must be able to perform these functions with or without reasonable accommodation. The organization will engage in a timely, good-faith interactive process when an accommodation is requested or the need for accommodation is known.

MARGINAL / OCCASIONAL FUNCTIONS

• Assists with newprovider onboarding logistics, such as coordinating badge/system access requests and EHR setup with IT.
• Prepares periodic credentialing status reports and audit documentation for practice leadership upon request.

SUPERVISORY RESPONSIBILITIES

None. This position does not directly supervise other employees.

MINIMUM REQUIRED QUALIFICATIONS

• Education: High school diploma or equivalent required; associate degree in healthcare administration or a related field preferred.
• Experience: Minimum two years of experience in medical staff credentialing, provider enrollment, or healthcare administration; experience in a surgical or hospitalaffiliated setting preferred.
• Licensure/Certification: None required to enter the role.
• Knowledge/Skills: Working knowledge of NCQA, payer, and hospital credentialing and privileging standards; proficiency with CAQH ProView, payer enrollment portals, and credentialing databases; strong attention to detail, organizational skills, and clear written communication; ability to maintain confidentiality of sensitive provider information.
• Other: Must be able to pass a background check as required for employment in a healthcare setting.

PREFERRED QUALIFICATIONS

• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) certification; experience credentialing surgeons or proceduralists; familiarity with PECOS, NPPES, and major commercial payer enrollment systems