Credentialing Specialist

Credentialing Specialist

Job Summary

The Credentialing Specialist is responsible for managing the credentialing and re-credentialing processes for healthcare providers and facilities, ensuring compliance with all relevant regulations and standards. This role involves reviewing applications, maintaining accurate provider data, and coordinating with payers and regulatory agencies to facilitate provider enrollment. The ideal candidate will possess a strong understanding of healthcare compliance, managed care, and medical credentialing software to support the organization’s accreditation and regulatory requirements. This position offers an opportunity to contribute to healthcare quality assurance and regulatory adherence within a dynamic healthcare environment.

Responsibilities

• Review and verify medical credentialing applications in accordance with industry standards such as NCQA, JCAHO, and CMS regulations.
• Manage provider enrollment processes with various health payers, including Medicare, Medicaid, and commercial insurers.
• Maintain accurate and up-to-date provider data within healthcare software applications and databases.
• Ensure compliance with federal, state, and local healthcare regulations, including CMS regulatory compliance and health regulation policies.
• Prepare and submit credentialing documentation for accreditation standards (regulatory compliance area) and manage ongoing re-credentialing activities.
• Collaborate with healthcare providers to gather necessary documentation while handling confidential information securely.
• Monitor changes in healthcare policies, payer requirements, and accreditation standards to ensure ongoing compliance.
• Assist in contract management related to provider agreements and credentialing processes.
• Support internal teams by providing credentialing status updates and resolving issues related to provider enrollment or re-credentialing.
• Maintain detailed records of credentialing activities in accordance with healthcare compliance protocols.

Experience

• Proven experience in medical credentialing within a managed care or healthcare setting.
• Strong familiarity with healthcare software applications, including medical credentialing software systems.
• Knowledge of health insurance policies, payer enrollment procedures, and CMS regulations such as those from the Centers for Medicare and Medicaid Services (CMS).
• Experience working with healthcare accreditation standards (NCQA, JCAHO) and regulatory compliance requirements.
• Background in administrative roles within healthcare environments, preferably involving database management and contract oversight.
• Understanding of medical terminology, health regulation policies, and healthcare compliance protocols.
• Prior experience handling confidential information with discretion in accordance with HIPAA or equivalent standards.

This role is integral to maintaining the organization’s reputation for excellence in healthcare delivery through rigorous credentialing practices that meet all regulatory standards.

Job Types: Part-time, Contract, Temporary, Temp-to-hire, PRN

Pay: $25.00 - $36.00 per hour

Expected hours: 8 – 32 per week

Work Location: In person