The Credentialing Specialist plays a vital role in ensuring that all healthcare providers and licensed or certified staff are properly credentialed and in compliance with internal standards and external regulatory requirements. The position is responsible for end-to-end credentialing and recredentialing processes and maintaining and updating the credentialing software systems.

Credentialing & Privileging

• Collect, review, and process initial credentialing and recredentialing applications.
• Ensure completeness and accuracy of all documentation, including licenses, certifications, malpractice insurance, CME, and related credentials.
• Verify provider credentials such as education, training, licensure, board certifications, employment history, and references.
• Conduct primary source verification by contacting licensing boards, educational institutions, and prior employers.
• Process initial and reappointment applications for all licensed or certified staff.
• Ensure providers are appropriately privileged and proctored according to regulatory and organizational requirements.
• Query the National Practitioner Data Bank (NPDB) for OCLPs at initial credentialing and reappointment.
• Track credentialing deadlines and monitor timely renewal of licenses, DEA registrations, certifications, and other required documents.
• Identify and resolve discrepancies, omissions, or inconsistencies in credentialing files.
• Escalate non-compliance related to licensure, certification, documentation, or reappointment.

Compliance & Quality Assurance

• Ensure credentialing and privileging practices meet organizational standards, NCQA requirements, and state or regulatory agency guidelines.
• Investigate complaints against providers and support resolution.
• Maintain current ProAssurance malpractice certificates and non-TrueCare liability insurance.
• Audit credentialing databases to ensure accuracy and data integrity.
• Generate and distribute credentialing reports and prepare files for committee review.

Systems & Data Management

• Maintain and update provider information in credentialing databases such as MD-Staff, CAQH, and NPPES.
• Ensure accuracy, completeness, and timely entry of credentialing data.
• Notify all health plan entities of provider changes, including terminations and updated business addresses.
• Collaborate with the Provider Enrollment Specialist to ensure timely processing of all health plan enrollments.

Collaboration & Communication

• Work closely with the Sr. Medical Staff Director to recommend improvements to credentialing and privileging workflows.
• Communicate with providers, internal teams, and stakeholders to obtain missing documents and resolve inquiries.
• Provide guidance and support to other credentialing staff.
• Process Continuing Medical Education (CME) and licensing reimbursement requests.

• Ensure credentialing and privileging practices meet organizational standards, NCQA requirements, and state or regulatory agency guidelines.
• Investigate complaints against providers and support resolution.
• Maintain current ProAssurance malpractice certificates and non-TrueCare liability insurance.
• Audit credentialing databases to ensure accuracy and data integrity.
• Generate and distribute credentialing reports and prepare files for committee review.

Qualifications: 

• Associate’s degree in Business, Healthcare Administration or related field.
• 4 to 5 years’ experience with the credentialing and privileging process for licensed independent providers (LIPs).
• Strong organizational skills and attention to detail.
• Possesses solid working knowledge of subject matter.
• Experience with primary source verifications and collections of credentialing and privileging documentation.

Preferred Qualifications:

• Bachelor’s Degree preferred.
• MD Staff Credentialing Software knowledge.
• National Association Medical Staff Services Certification (NAMSS).
• Certified Provider Credentialing Specialist (CPCS).
• Certified Professional Medical Staff Management (CPMSM).
• Experience in healthcare or working in a Federally Qualified Health Center.