Credentialing Specialist

Overview:

The Credentialing Specialist role Involves verifying and maintaining the qualifications and credentials of healthcare providers, ensuring they meet the requirements set by payor organizations (insurance companies, government programs, etc.) to receive reimbursement for services rendered and setting up new healthcare providers credentials with certain facilities. This role is essential in maintaining compliance with insurance policies and regulations and ensuring that healthcare providers are properly authorized to deliver services to patients. Aside from credentialing duties, this role will assist the HR Manager and Accounting Manager with

Key Responsibilities:

Credentialing Providers:

• Collect, verify, and maintain the necessary documentation for healthcare providers (e.g., medical licenses, board certifications, malpractice insurance, and educational qualifications).
• Ensure that providers meet the specific credentialing requirements of payor organizations, hospitals, and healthcare networks.
• Submit credentialing applications to insurance companies, government programs (e.g., Medicare, Medicaid), and other payor entities.
• Review and update provider credentialing files regularly to ensure compliance with regulatory changes and policies.

Liaising with Payors:

• Serve as the point of contact between healthcare providers and payor organizations (insurance companies, health plans).
• Coordinate and manage the credentialing process for both in-network and out-of-network providers.
• Track credentialing and re-credentialing cycles to ensure timely updates and prevent delays in reimbursements or provider access.

Ensuring Compliance:

• Ensure all provider credentials are compliant with state, federal, and industry regulations (e.g., NCQA, URAC).
• Assist in maintaining adherence to payer-specific credentialing standards and guidelines.
• Investigate and resolve any discrepancies or issues in provider credentials as they arise.
• Monitor and track deadlines for re-credentialing or renewals and ensure all documents are submitted before expiration.

Maintaining Provider Databases:

• Maintain and update comprehensive provider databases with accurate and current credentialing information.
• Track and manage provider changes, such as name changes, address updates, or license expirations, and ensure updates are reflected in payer systems.
• Verify ongoing participation status of providers with insurance carriers and health plans.

Credentialing Audits and Reports:

• Prepare and manage credentialing reports for internal stakeholders or regulatory bodies as required.
• Support audits and inquiries from payors, regulatory agencies, and other external organizations regarding provider credentialing.
• Assist in the preparation of documentation for audits, ensuring all records are up to date and compliant with regulatory standards.

Onboarding and Education:

• Assist in the onboarding process for new healthcare providers by ensuring all necessary credentials and documentation are submitted.
• Educate providers and internal staff on credentialing requirements, policies, and procedures.
• Provide guidance and support to providers in understanding the credentialing process and addressing any concerns they may have.

Cross-Department Collaboration:

• Work closely with other departments, such as billing, compliance, and legal teams, to ensure smooth provider onboarding and compliance with payer requirements.
• Collaborate with healthcare facilities or medical group administrators to facilitate provider credentialing.

Assist HR and Accounting Departments:

• HR tasks to include employee file upkeep, maintaining provider and medical staff licensure and certifications, employee onboarding, assigning training
• Accounting tasks to include: sorting mail and related paperwork, data entry for bills and payables

Skills and Qualifications:

• A high school diploma or equivalent is required, though a bachelor’s degree in healthcare administration, business, or a related field is preferred.
• 1-2 years of experience in healthcare credentialing, medical office administration, or insurance/claims processing is typically required.
• Proficiency with credentialing software (e.g., CAQH, Verisys) and other administrative tools (e.g., MS Office, databases).
• Strong ability to ensure accuracy and compliance with documentation, procedures, and regulatory standards.
• Excellent communication skills for interacting with providers, payors, and internal teams. Ability to explain complex credentialing processes clearly.
• Ability to manage multiple tasks, deadlines, and providers simultaneously, ensuring that credentialing requirements are met on time.

Knowledge of Credentialing and Regulatory Standards:

• Familiarity with credentialing requirements, including knowledge of federal and state regulations (e.g., HIPAA, CMS, NCQA, URAC).
• Understanding of payor-specific credentialing policies and procedures (e.g., Medicare, Medicaid, commercial insurance).

Schedule Expectations:

• Monday thru Friday, with occasional overtime as needed
• Possibility of one (1) weekly work from home day dependent on employee’s performance, following a 90-day probationary period

If you are passionate about supporting healthcare providers through the credentialing process while ensuring compliance with industry standards, we encourage you to apply for this vital role within our organization.

Job Type: Full-time

Pay: From $20.00 per hour

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Employee assistance program
• Flexible spending account
• Health insurance
• Health savings account
• Life insurance
• Paid time off
• Referral program
• Retirement plan
• Vision insurance

Schedule:

• 8 hour shift
• Day shift
• Monday to Friday

Work Location: In person

Salary : $20