Credentialing Specialist

Role overview

The Credentialing Specialist supports the intake and processing of a large number of initial provider applications, including Allied Health Professionals. This role operates within Credentialing and reports to the Credentialing Manager. The position focuses on ensuring applications are handled in line with internal procedures, CMS and NCQA expectations, and applicable credentialing regulations. The specialist also maintains the accuracy of CAQH records and credentialing tracking systems, while serving as a point of contact between credentialing services, providers, and health plans.

Core duties

• Prepare and complete provider applications using primary source verification.
• Spot any adverse actions related to providers and record them for review.
• Examine finished applications before they are sent to the Credentialing Committee for approval.
• Confirm that provider files contain current licenses and certification records.
• Coordinate with administrative staff, when needed, to collect information required for IPA-related work.
• Use a solid working knowledge of credentialing terms, documents, and external research systems to locate necessary information.
• Maintain provider profiles in the practice management platform.
• Support IPA coordination activities and help ensure providers are fully utilized.
• Submit credentialing and reappointment materials to IPAs and health plans in a timely and ongoing manner.
• Assist providers with credentialing applications when support is needed.
• Monitor pending applications and alert the Manager to any issues obtaining provider details.
• Review credentialing documents carefully to confirm they are accurate, consistent, and compliant with regulatory standards.
• Coordinate medical director review and approval of clean files.
• Prepare credentialing materials for the Risk Management and Compliance Committee.
• Prepare files for approval by the Medical Director and Credentialing Committee.
• Support the Manager with credentialing audits.
• Work with all relevant parties to resolve routine credentialing questions and requests.
• Keep CAQH and credentialing tracking databases accurate and up to date.
• Follow payroll rules and use the timekeeping system correctly with minimal manual adjustments.
• Maintain dependable, regular attendance.
• Comply with the organization’s Compliance Plan and HIPAA requirements.

Additional responsibilities

• Handle special projects as assigned.
• Carry out other related duties as needed.

Behavioral expectations

• Keep learning by attending required staff meetings, training sessions, seminars, and workshops.
• Protect client and customer confidentiality and privacy in line with HIPAA and standards of conduct.
• Communicate well and maintain positive working relationships with supervisors, colleagues, and other staff.
• Report security, health, or safety concerns to the appropriate supervisor as soon as practical.
• Support safe work practices in all job activities.
• Follow established policies and procedures and comply with all applicable regulatory standards.

Requirements

This role calls for a high school diploma or equivalent, along with 2 to 3 years of credentialing experience in a hospital, medical staff office, or health plan. Strong experience with CAQH and the ICE Checklist is required, and primary source verification experience is preferred.

Skills and knowledge

The position requires proficiency with Microsoft Word, Excel, and Adobe Acrobat, plus the ability to read, write, speak, and understand English clearly. The candidate must be comfortable following written and verbal directions in English, maintaining confidentiality, interacting professionally with customers and coworkers, managing multiple priorities, exercising sound judgment, solving problems promptly, and working independently with initiative. Familiarity with federal, state, and local regulations is also important.

Certification note

CPCS or CMSC certification is considered an added advantage.