Credentialing Specialist II

Description

Job Type Full-time

Description $60,000 

We are currently seeking a Credentialling Specialist II to act as primary lead and subject matter expert overseeing all database systems, workflows, and processes related to provider credentialing and payer enrollment. In this role you will be responsible for ensuring optimal functionality, accuracy, and compliance across the credentialing database and enrollment processes for all service lines, ensuring adherence to FQHC standards and regulatory requirements. Additionally, you will act as the key expert on payer enrollment requirements, guiding internal teams and stakeholders to ensure timely and accurate enrollment with Medicare, Medicaid, and private payers. 

General job duties:  

Credentialing Database & Workflow Oversight:

• Serve as the organizational lead responsible for managing and maintaining the credentialing database, ensuring data integrity, efficiency, and compliance with federal, state, and payer regulations.
• Develop, implement, and refine credentialing workflows and processes to support operational efficiency and ensure consistency across all departments and service lines.
• Coordinate and monitor the credentialing process for all healthcare providers, including licensed independent providers and clinical support staff.
• Verify and update licensure, certifications, education, and qualifications, ensuring primary source verification and compliance standards are met.
• Ensure timely initial and renewal credentialing, including licensure, certifications, privileges, and board approvals.
• Continuously monitor credentialed staff for any sanctions, exclusions, or disciplinary actions, including NPDB, OIG, SAM, and Ohio Medicaid Exclusion lists.
• Oversee all credentialing file maintenance and management within the database, including initial and re-credentialing documentation, expiration dates, and audit readiness.
• Facilitate internal and external audits, ensuring that credentialing records are accurate and audit-ready at all times.
• Oversee single case agreements and credentialing-related hospital privileges for specialized providers.

Subject Matter Expert in Payer Enrollment:

• Act as the subject matter expert (SME) for all payer enrollment processes across all service lines and departments.
• Lead the payer enrollment process, including preparation, submission, and maintenance of enrollment applications and documentation for Medicare, Medicaid, private insurance, and managed care organizations.
• Monitor payer enrollment statuses, troubleshoot delays, and implement solutions to ensure expedited processing.
• Maintain and update all payer contracts, enrollment statuses, fee schedules, CAQH profiles, and expiration/renewal timelines within the database.
• Collaborate with revenue cycle, billing, and finance teams to ensure accurate and timely provider enrollment information, facilitating smooth reimbursement processes.
• Keep up to date with evolving payer enrollment requirements, FQHC regulations, and payer-specific policies, communicating changes and ensuring ongoing compliance.
• Respond promptly to inquiries regarding credentialing and payer enrollment processes from both internal teams and external entities.

Compliance Leadership:

• Ensure credentialing and enrollment activities are fully compliant with FQHC guidelines, HRSA, CMS, TJC, CARF, and other regulatory bodies.
• Collaborate with compliance, risk management, and quality teams to regularly audit credentialing and enrollment processes, implement corrective actions, and support continuous improvement efforts.
• Stay informed about federal, state, and payer regulations, ensuring Third Street remains compliant with all credentialing and enrollment standards.

Communication & Collaboration:

• Serve as the lead point of contact for all credentialing and payer enrollment matters, providing guidance and expertise to internal staff, leadership, and external stakeholders.
• Coordinate closely with human resources, billing, finance, legal, and clinical teams to align credentialing and enrollment efforts with broader organizational priorities.
• Maintain open communication channels with payers, credentialing organizations, and regulatory agencies to facilitate efficient processes and address issues promptly.
• Act as a positive role model, fostering collaboration and knowledge-sharing across departments.

Third Street is an equal opportunity employer. Our goal is to be a diverse workforce that is representative, at all job levels, of the communities and patients we serve. We do not discriminate on the basis of race, color, religion, marital status, age, national origin, ancestry, physical or mental disability, medical condition, pregnancy, genetic information, gender, sexual orientation, gender identity or expression, veteran status, or any other status protected under federal, state, or local law. If you require reasonable accommodation in completing this application, please direct your inquiries to hr@thirdstreetfamily.org or call 419-522-6191 ext. 2201 for Human Resources. 

What We Offer:

Attending to your needs today:

• Your ideas, input, and contributions are valued and recognized.
• Excellent clinical, administrative, and management support
• Forward-thinking, collaborative, transparent, and inclusive company culture
• Employee Assistance Program
• Competitive Medical, Dental, and Vision plans
• Competitive compensation
• Paid Time Off
• Wellness Reimbursement Program
• Tuition assistance

Protecting your future:

• Medical, dental and vision insurance
• 403(b) retirement plan
• Employer-paid life insurance
• Employer-paid long-term disability

Requirements

 Qualifications: 

• Bachelor's degree in healthcare administration or health information management
• Previous experience in credentialing and payor enrollment within a healthcare setting, preferably FQHC required. 
• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) from NAMSS or the Certified Professional in Health Quality (CPHQ) from NAHQ
• Experience in credentialing software/database systems, required.

About Us: Third Street is a patient-centered medical home driving change in the community. We adapt to the needs of those we serve while building services to fill gaps in care to invest in a healthier future for all. At Third Street, we provide high-quality care through the continual learning of our employees and by building a diverse team. We value our employees, communicate our expectations, and train our team on best practices.

Organizational Information:

• Established in 1994, Third Street Family Health Services is a regional not-for-profit community health center providing medical, dental, OB/GYN, pediatric, community outreach, and behavioral health services across eleven locations in Richland, Marion, Ashland, and Crawford counties. Our mission is to deliver comprehensive health and wellness care, accessible to all in the communities we serve. We believe that the health status of our community can be improved by providing accessible and affordable health care, advocacy, and community health initiatives.
• We provide patient-centered care and provide our services with respect, integrity, and accountability top of mind. For more information, visit tsfhs.org or find them on Facebook or Twitter.

Mission:
To deliver comprehensive health and wellness care, accessible to all in the communities we serve. 

Salary : $60,000