Credentialing Specialist

Job Title: Credentialing Specialist Job Status: Full-time

Job Summary: Under general supervision, the Credentialing Specialist will play a critical role in supporting the Community Health & Research Center fee for service environment, the billing division, and contributing to patient safety and satisfaction. This role is responsible for ensuring that healthcare professionals and facilities maintain appropriate credentials and meet all regulatory and organizational standards in ensuring that physicians and other healthcare providers meet all necessary qualifications and standards. This role manages the credentialing process to support the delivery of quality healthcare services and maintaining the integrity and quality of healthcare expertise.

Essential Duties and Responsibilities:

• Verify the credentials, licensure, certifications, and qualifications of medical and healthcare professionals, and ensure compliance with relevant regulations and industry standards
• Conduct thorough checks of educational background, training, licensure, certification, and work experience of healthcare providers and ensure the accuracy of completeness
• Maintain records of all credentialing activities, including updated information on licenses, certifications, and malpractice insurance
• Ensure that all healthcare providers comply with state and federal regulations, as well as industry standards and organizational policies
• Oversee the re-credentialing process for all health care providers and ensure timely renewal of credentials and certifications, avoiding any lapse in compliance
• Verify the accuracy of health care provider information, including education, training, experience, and licensure
• Maintain and update credential files and databases, warranting compliance with current regulations and standards
• Communicate with healthcare providers, regulatory agencies, and other stakeholders to resolve credentialing issues
• Coordination between healthcare providers, insurance companies, and regulatory agencies, facilitating timely and accurate exchange of information
• Prepare and present credential reports to management and relevant committees
• Assist in preparing for internal and external audits, providing necessary documentation and information to auditors
• Stay informed about changes in healthcare regulations and credentialing requirements
• Operate standard office equipment and use required software applications
• Perform other duties and responsibilities as assigned

Knowledge, Skills, and Abilities:

• Knowledge of:
• Credentialing regulations, policies, and procedures
• Relevant state and federal regulations, as well as standards set by accrediting bodies such as The Joint Commission (TJC) and the National Committee for Quality Assurance (NCQA)
• Healthcare regulations and compliance standards
• Proficiency in:
• Credentialing software and databases, as well as standard office applications
• Microsoft Office
• Skill in:
• Strong attention to detail and organizational skills
• Excellent written and verbal communications and interpersonal skills
• Excellent organizational skills to manage multiple tasks and deadlines effectively
• Operating standard office equipment and using required software applications
• Ability to:
• Manage multiple deadlines
• Mutti task and able to negotiate and coordinate between multiple entities in order to solve issues
• Be patient, self-control and provide a solution to issues
• Build positive relationships with healthcare providers
• Demonstrate a high degree of trust and confidentiality
• Work independently

Educational/Previous Experience Requirements:

• Minimum Degree Required: Bachelors degree
• Required Disciplines: Healthcare Administration, Business Administration, or a related field
• 3 to 5 years experience or any equivalent combination of experience, education and/or training approved by Human Resources
• Licenses/Certifications: (CPCS), Certified Provider Credentialing Specialist is strongly preferred

Working Conditions:

• Hours: Normal business hours, some additional hours may be required
• Travel Required: None generally required; Local, in-state, national, and international travel, up to 10%
• Working Environment: Climate controlled office