Credentialing Specialist : Description
The Credentialing Specialist is responsible for coordinating and maintaining all aspects of the provider credentialing, recredentialing, enrollment, and privileging processes. This position ensures healthcare providers meet all federal, state, payer, and organizational requirements necessary to participate in healthcare networks and deliver services within the organization. The Credentialing Specialist works closely with providers, health plans, regulatory agencies, and internal departments to ensure timely and accurate credentialing activities while maintaining compliance with applicable regulations and accreditation standards.
The ideal candidate possesses strong organizational, communication, and problem-solving skills, along with a thorough understanding of healthcare credentialing regulations, Medicare enrollment requirements, and provider data management.
- Coordinate and process initial credentialing, recredentialing, privileging, and provider enrollment applications.
- Verify provider credentials through primary source verification, including licensure, education, training, board certification, employment history, malpractice coverage, and professional references.
- Ensure providers meet all credentialing requirements and maintain compliance with organizational, federal, state, and payer standards.
- Prepare, submit, track, and maintain Medicare, Medicaid, and commercial payer enrollment applications and revalidations.
- Maintain provider records and databases, ensuring accuracy and completeness of credentialing documentation.
- Monitor expiration dates for licenses, DEA registrations, board certifications, malpractice insurance, and other required credentials to ensure timely renewals.
- Conduct sanctions screening and exclusion monitoring through OIG, SAM, state exclusion databases, and other regulatory sources.
- Communicate with healthcare providers, health plans, hospitals, and regulatory agencies regarding credentialing and enrollment requirements.
- Assist providers with completing credentialing and enrollment applications and resolving documentation deficiencies.
- Ensure compliance with CMS, NCQA, Joint Commission, URAC, payer, and state regulatory requirements.
- Maintain confidentiality of provider information and adhere to HIPAA regulations.
- Prepare reports and maintain credentialing tracking logs to ensure timely processing and compliance.
- Participate in credentialing audits, accreditation reviews, and compliance initiatives.
- Stay current on changes to credentialing regulations, payer requirements, and industry best practices.
- Collaborate with internal departments to support provider onboarding and network participation.
- Perform other related duties as assigned.
- Associate or bachelor’s degree in healthcare administration, Business Administration, Human Resources, or a related field preferred.
- Minimum of 2–3 years of provider credentialing experience in a healthcare organization, medical group, hospital, or Medicare-managed care environment.
- Thorough knowledge of CMS (Centers for Medicare & Medicaid Services) regulations, Medicare enrollment requirements, and provider credentialing standards.
- Experience credentialing and recredentialing physicians, nurse practitioners, physician assistants, and ancillary healthcare providers.
- Proficiency with CAQH, PECOS, NPPES, Medicare enrollment applications, and provider data management systems.
- Familiarity with NCQA, URAC, Joint Commission, and state regulatory requirements related to provider credentialing and compliance.
- Knowledge of Florida healthcare licensing requirements and state-specific credentialing regulations.
- Experience conducting primary source verification, license monitoring, sanctions screening, and exclusion checks through OIG, SAM, and state exclusion databases.
- Strong understanding of payer enrollment, provider contracting, privileging, and recredentialing processes.
- Advanced proficiency in Microsoft Office Suite, including Excel, Word, and Outlook.
- Ability to maintain strict confidentiality and handle sensitive provider information in compliance with HIPAA regulations.
- Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) designation preferred.
- Experience working with Medicare Advantage plans, managed care organizations, and value-based care networks.
- Bilingual (English/Spanish) preferred.
- Experience using credentialing software platforms such as Modio Health, VerityStream, symplr, or similar systems.
- Experience supporting accreditation reviews, audits, and compliance initiatives.
- Exceptional organizational and time-management skills.
- Strong attention to detail and accuracy.
- Excellent written and verbal communication skills.
- Ability to manage multiple deadlines and prioritize tasks in a fast-paced healthcare environment.
- Strong problem-solving and analytical skills.
- Ability to collaborate effectively with providers, leadership, health plans, and regulatory agencies.
- Customer-service-oriented mindset with professionalism and responsiveness.
- Ability to work independently while maintaining a high level of accuracy and accountability.
Occasional travel to assigned clinics, provider offices, or corporate locations may be required.
This position works under normal office conditions. The employee is required to work on a personal computer and communicate by telephone and email for extended periods. Must be able to sit, stand, walk, bend, and occasionally lift to 20 pounds. The incumbent may be required to work flexible hours as business needs dictate.
The intent of this job description is to provide a representative summary of the major duties and responsibilities performed by employees assigned to this position. It is not intended to be an exhaustive list of all responsibilities, duties, and skills required.
Employees may be required to perform other job-related duties as assigned.
To apply for the Credentialing Specialist position, please fill out the following form:
