Medical Insurance Credentialing and Facility Privileging Specialist

Job Description

We are seeking a detail-oriented and organized Medical and Behavioral Health Insurance Credentialing and Facility Privileging Specialist to join our team. This role is responsible for managing the credentialing and recredentialing process for healthcare providers to ensure compliance with all relevant insurance plans and regulatory standards. The ideal candidate will have a strong understanding of credentialing procedures, excellent communication skills, and the ability to manage multiple tasks effectively. This position is critical in ensuring that healthcare providers and facilities meet the necessary qualifications and standards, thereby contributing to the overall success of the organization.

Key Responsibilities:

• Credentialing Process Management:
• Gather, verify, and submit all required documentation for provider credentialing with insurance companies and healthcare organizations.
• Maintain and update credentialing files to ensure compliance with federal, state, and payer-specific standards.
• Verification and Compliance:
• Verify healthcare providers’ credentials, including education, training, licensure, certifications, disciplinary actions, malpractice insurance, and work history.
• Ensure compliance with federal, state, and payer-specific standards and requirements.
• Provider Enrollment:
• Enroll providers in Medicare, Medicaid, and commercial insurance networks.
• Monitor and track the status of applications, provide updates to stakeholders and resolve issues promptly.
• Oversee the privileging process for healthcare providers at affiliated facilities.
• Collaborate with hospitals, clinics, and other facilities to ensure timely submission and approval of privileges.
• Maintain records of privileging status and renewal timelines.
• Database Management:
• Input and manage provider data in credentialing and practice management software and tracking systems.
• Ensure accuracy and completeness of information, including licenses, certifications, and insurance policies.
• Compliance:
• Stay current on industry regulations and insurance requirements to ensure all providers maintain compliance.
• Conduct periodic audits of credentialing records to identify and resolve discrepancies.
• Monitor compliance with credentialing and privileging standards set by accreditation organizations (e.g., The Joint Commission, NCQA).
• Communication:
• Serve as the primary point of contact for providers, insurance companies, facility administrators and internal departments regarding credentialing matters.
• Respond to inquiries and provide timely resolution to credentialing-related concerns.
• Reporting:
• Generate and submit reports on credentialing status, expirations, and renewals to management.
  

Qualifications:

• Education:
• High school diploma or equivalent required. Associate or bachelor’s degree in healthcare administration or related field preferred.
• Experience:
• Minimum of 2–3 years of experience in medical credentialing, insurance enrollment, and/or facility privileging.
• Knowledge of insurance enrollment processes and credentialing standards (e.g., CAQH, NCQA).
• Skills and Competencies:
• Strong organizational and time management skills.
• Proficiency in credentialing software and Microsoft Office Suite (Word, Excel, Outlook).
• Excellent organizational skills and attention to detail.
• Strong written and verbal communication skills.
• Detail-oriented with the ability to handle sensitive information confidentially.
• Ability to manage multiple tasks and deadlines efficiently.
  
  

• Key Competencies:
• Analytical thinking and problem-solving skills are a must-have.
• Ability to prioritize tasks and meet deadlines in a fast-paced environment.
• Strong customer service orientation and professional demeanor.
  

Working Conditions:

• Remote work flexibility.
• May require occasional interaction with external agencies and insurance representatives.
  
  

Benefits:

• Competitive compensation. May be eligible for incentive programs based on company and individual performance
• Health, dental, and vision insurance
• Paid time off (PTO)
• Retirement plan with employer match
  
  

Equal Opportunity Employer Statement:

Oasis Claim Management Solutions, Inc. is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.

To apply, please submit your resume and a cover letter detailing your relevant experience.