The Credentialing Specialist works closely with providers, management, hospitals, insurance payers, and regulatory agencies to maintain accurate and timely credentialing records.
General Summary of Duties: (Other duties may be assigned.)
- Coordinate and manage provider credentialing and recredentialing processes for physicians, physician assistants, nurse practitioners, therapists, and other clinical staff.
- Prepare and submit credentialing applications to commercial insurance carriers, Medicare, Medicaid, hospitals, surgery centers, and other healthcare organizations.
- Maintain accurate provider files, credentialing databases, and tracking systems.
- Monitor expiration dates for licenses, DEA registrations, board certifications, malpractice insurance, ACLS, CPR certifications, and other required credentials.
- Ensure timely completion of payer enrollment and revalidation applications.
- Follow up with insurance carriers and facilities regarding application status and approvals.
- Maintain CAQH profiles and ensure all provider information is current and attested as required.
- Assist with provider privileging and hospital appointment processes.
- Verify provider credentials including education, training, licensure, certifications, malpractice coverage, and work history.
- Ensure compliance with federal, state, payer, and accreditation standards.
- Communicate with providers regarding missing documentation and renewal requirements.
- Maintain confidentiality of provider and organizational information.
- Assist with audits, reports, and credentialing documentation requests.
- Collaborate with billing, compliance, human resources, and administrative staff regarding provider enrollment and credentialing matters.
- Perform other duties as assigned.
Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required.
Education and Training:
- High School diploma or equivalent required at minimum
- Experience in physician practice credentialing, within an orthopaedic or specialty medical practice, preferred.
- Knowledge of Medicare, Medicaid, and commercial payer enrollment processes preferred.
- Knowledge of healthcare regulations, payer requirements, and credentialing standards.
- Excellent organizational skills and attention to detail.
- Ability to manage multiple deadlines and prioritize tasks effectively.
- Strong written and verbal communication skills.
- Proficient in Microsoft Office applications and credentialing software/databases.
- Ability to maintain confidentiality and handle sensitive information appropriately.
Physical Demands and Working Conditions/Requirements:
- Requires prolonged periods of sitting at desk, working at computer, and being on the phone
- Must have good computer and telephone communication skills and able to operate miscellaneous office equipment
- Hearing and vision abilities within normal range, or corrected, to observe and communicate with patients and staff
- Ability to work in fast-paced environment in a professional medical office setting
- Reasonable accommodations may be made to enable individuals with disabilities to perform the necessary functions
Position Type and Expected Hours of Work:
Full-time: 40 hours minimum per week; available for overtime as needed; varied day shift hours on weekdays
Travel Requirements:
May require occasional travel between office locations or facilities.
Full-time Benefits
- Health, Dental, and Vision Insurance
- 401k Plan, 3% Safe Harbor Non-Elective Employer Contribution
- Employer-provided $25,000 Group Life Insurance
- Voluntary Life Insurance
- Short-Term and Long-Term Disability
- Accident, Hospital, Critical Illness/Cancer Benefits
- Mileage Reimbursement for travel between office locations
- Certificate and Continuing Education Reimbursement
- Accrual Paid Time Off (up to 19 days off within 1st year)
- 6 Paid Holidays Per Year
- Closed on Major Holidays
