Credentialing and Licensing Specialist III

Job Description Summary

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The Credentialing and Licensing Specialist III performs advanced-level credentialing and licensing work for healthcare providers to ensure compliance with regulatory, accreditation, payer, and organizational requirements. Reviews, validates, tracks, and maintains provider credentialing documentation, licensure records, certifications, enrollment information, and related provider data. Coordinates with providers, internal stakeholders, licensing boards, payers, and external agencies to resolve credentialing and licensing matters and support timely credentialing, recredentialing, enrollment, and renewal activities.

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How will you make an impact & Requirements

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Key Responsibilities

• Process provider credentialing, recredentialing, licensing, enrollment, and renewal activities.
• Review and validate credentialing documentation, including licenses, certifications, education, training, malpractice coverage, work history, sanctions, exclusions, and other required provider information.
• Research and resolve non-routine credentialing, licensing, payer enrollment, or provider data discrepancies, escalating complex compliance or regulatory concerns when needed.
• Monitor expiration dates, application status, missing documentation, and renewal timelines to support timely provider participation and compliance.
• Maintain provider records and credentialing databases with a high degree of accuracy, completeness, and data integrity.
• Communicate with providers, licensing boards, payers, credentialing committees, regulatory agencies, and internal stakeholders regarding requirements, status updates, and issue resolution.
• Support audits, accreditation reviews, compliance reporting, and credentialing committee preparation by gathering documentation, validating records, and responding to information requests.
• Provide informal training, guidance, or quality review support to less experienced credentialing staff on systems, procedures, and documentation standards as needed.

Qualifications

• High school diploma required; associate degree preferred.
• 3–5 years of credentialing, licensing, provider enrollment, healthcare administration, or related experience.
• In-depth knowledge of provider credentialing, recredentialing, licensing, payer enrollment, and provider data management processes.
• Working knowledge of applicable regulatory, accreditation, payer, and organizational credentialing requirements; familiarity with NCQA, CMS, state licensing, or related standards preferred.
• Experience using credentialing software, provider databases, payer portals, or HRIS/provider data systems preferred.
• Strong attention to detail, follow-through, organization, and ability to manage multiple deadlines and documentation requirements.
• Ability to resolve non-routine issues, interpret established procedures, and communicate effectively with providers, payers, agencies, and internal stakeholders.
• CPMSM, CPCS, or equivalent certification preferred but not required.