Job Title: Healthcare Credentialing Specialist
Department: Administration
Reports To: Executive Team & Director of Quality and Risk
Job Summary:
The Healthcare Credentialing Specialist is a vital member of our team, responsible for ensuring that all healthcare providers are properly credentialed and privileged in accordance with regulatory standards, accreditation requirements, and organizational policies. This role involves meticulous verification of provider qualifications, maintenance of accurate records, and seamless coordination with various internal and external stakeholders to support patient safety and operational compliance.
Key Responsibilities:
- Credentialing and Re-credentialing:
- Manages the end-to-end credentialing and re-credentialing process for physicians, allied health professionals, and other licensed providers.
- Collects, reviews, and processes initial and re-appointment applications, ensuring all required documentation is complete and accurate.
- Conducts comprehensive primary source verification (PSV) of education, licensure, board certifications, work history, malpractice history, and other relevant qualifications.
- Performs thorough background checks and sanctions screenings (e.g., OIG, SAM, NPDB).
- Collaborates with providers to obtain missing information and resolve discrepancies in a timely manner.
- Compliance and Regulatory Adherence:
- Ensures strict adherence to all federal, state, and local regulations, as well as standards set by accrediting bodies (e.g., NCQA, The Joint Commission, CMS).
- Stays current with changes in healthcare laws, regulations, and credentialing best practices, updating internal processes accordingly.
- Assists in preparing for and participating in internal and external audits and accreditation reviews.
- Database Management and Record Keeping:
- Maintains accurate and up-to-date provider data in credentialing software systems (e.g., VerityStream, symplr, CAQH).
- Tracks expiration dates for licenses, certifications, insurance, and other critical documents, proactively initiating renewal processes.
- Manages and organizes digital and physical credentialing files, ensuring confidentiality and integrity of sensitive information.
- Generates reports on credentialing status, turnaround times, and compliance metrics.
- Communication and Collaboration:
- Serves as a primary point of contact for providers, medical staff leadership, human resources, and other departments regarding credentialing matters.
- Communicates clearly and professionally with external entities such as licensing boards, educational institutions, previous employers, and insurance payers.
- Facilitates communication and documentation for credentialing committee meetings.
- Provides guidance and support to internal staff on credentialing and privileging processes.
- Process Improvement:
- Identifies opportunities to streamline and improve credentialing workflows and procedures.
- Contributes to the development and implementation of credentialing policies.
Qualifications:
- Education:
- Associate's or Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, or a related field preferred. A high school diploma or GED with significant relevant experience may be considered.
- Experience:
- Minimum of 2 years of experience in healthcare credentialing, medical staff services, or provider enrollment.
- Familiarity with regulatory and accreditation standards (e.g., NCQA, The Joint Commission).
- Certifications (Preferred but not required):
- Certified Provider Credentialing Specialist (CPCS) from the National Association Medical Staff Services (NAMSS)
- Certified Professional Medical Services Management (CPMSM) from NAMSS
- Skills & Abilities:
- Exceptional Attention to Detail: Meticulous in reviewing documents and data to ensure accuracy and identify discrepancies.
- Strong Organizational Skills: Ability to manage multiple tasks, prioritize effectively, and meet tight deadlines in a fast-paced environment.
- Excellent Communication Skills: Proficient in both verbal and written communication, with the ability to articulate complex information clearly and professionally to diverse audiences.
- Technical Proficiency: Competency in using credentialing software (e.g., VerityStream, symplr, CAQH), database management systems, and Microsoft Office Suite (Word, Excel, Outlook).
- Analytical and Problem-Solving Skills: Ability to investigate issues, analyze information, and propose effective solutions.
- High Level of Confidentiality and Ethical Conduct: Handles sensitive provider and patient information with utmost discretion.
- Ability to Work Independently and Collaboratively: Self-motivated and able to manage workload, while also contributing effectively to a team environment.
- Knowledge of Medical Terminology: Understanding of healthcare terms and concepts.
Physical Requirements:
- Ability to sit for extended periods.
- Manual dexterity to operate computer equipment and other office machinery.
· May require occasional lifting of light materials (up to 15 lbs).
Job Type: Full-time
Pay: From $45,000.00 per year
Benefits:
- Dental insurance
- Health insurance
- Paid time off
- Retirement plan
- Vision insurance
Schedule:
- 8 hour shift
- Monday to Friday
- No nights
Work Location: In person