Credentialing Specialist

POSITION TITLE: Credentialing Specialist

NATURE OF POSITION: The Credentialing Specialist is responsible for coordinating, monitoring, and maintaining the credentialing and privileging processes for all licensed independent practitioners and other clinical staff at Central Oklahoma Family Medical Center. This role ensures that all providers meet internal standards and comply with applicable federal and state laws, payer requirements, accreditation standards, and FQHC program requirements. The Credentialing Specialist manages initial credentialing, recredentialing, privileging, payer enrollment, and ongoing monitoring of providers' qualifications so that the organization can deliver safe, high-quality, and compliant patient care.

MINIMUM QUALIFICATIONS:

• High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business, or related field preferred.
• Strong attention to detail, organizational skills, and ability to manage multiple projects and deadlines.
• Effective written and verbal communication skills, including the ability to interact professionally with clinicians, staff, and external organizations.
• Ability to handle confidential information in compliance with organizational policy and applicable law.

Preferred But Not Required:

• Two (2) years of experience in healthcare credentialing, payer enrollment, or a related field, preferably within a community health center, FQHC, hospital, or large healthcare clinic environment.
• Working knowledge of:
• Credentialing concepts and primary source verification.
• Medicare and Medicaid provider enrollment processes, preferably in an FQHC, hospital, or healthcare clinic setting.
• Basic requirements related to provider licensure, DEA and OBNDD registration, board certification, and credential maintenance.
• Proficiency with Microsoft Office (Word, Excel, Outlook) and credentialing or practice management systems.
• Prior experience working in a Federally Qualified Health Center or community health setting preferred.
• Working knowledge of: HRSA Health Center Program requirements related to clinical staffing and quality, preferred.
• Knowledge of relevant CMS and payer enrollment regulations preferred.
• Experience with CAQH and major payer portals preferred.

RESPONSIBILITIES:

1. Provider Credentialing and Privileging

   • Coordinate and process initial credentialing and recredentialing for physicians, advanced practice providers (e.g., APRNs, PAs), behavioral health providers, dentists, and other licensed/credentialed staff with payers.
   • Maintain credentialing documents provided by the Medical Staff Coordinator for payers, which may include:
   • Professional licenses (e.g., Oklahoma Board of Medical Licensure and Supervision, Oklahoma State Board of Osteopathic Examiners, Oklahoma Board of Nursing, Oklahoma State Board of Behavioral Health, Oklahoma Board of Dentistry, etc.).
   • DEA and Oklahoma Bureau of Narcotics and Dangerous Drugs Control (OBNDD) registrations, as applicable.
   • Professional liability insurance coverage and claims history.
   • Education, training, residency/fellowship completion, board certifications, and continuing education.
   • Work history, references, and CVs.

2. Payer Enrollment and Provider Maintenance

   • Complete and submit provider enrollment and revalidation applications for Medicare, Medicaid (Oklahoma Health Care Authority/ SoonerCare), and commercial payers.
   • Maintain and update CAQH profiles and other payer portals as required.
   • Track and ensure timely responses to payer requests for additional information, revalidations, or updates.
   • Monitor effective dates and communicate enrollment status to billing and leadership teams to minimize reimbursement delays and claim denials.
   • Assist with payer onboarding providers by ensuring credentials and privileges are in place before start dates, consistent with FQHC program, state law, and payer requirements.

3. Ongoing Monitoring and Compliance

   • Help ensure that providers remain compliant with organizational policies, FQHC program requirements, and applicable federal and state laws and regulations.
   • Identify and report any adverse actions, gaps, or issues to appropriate leadership and assist in implementing corrective steps in accordance with policy.
   • Maintain awareness of, and help implement standards from:
   • Health Resources and Services Administration (HRSA) FQHC requirements (e.g., HRSA Health Center Program Compliance Manual expectations on clinical staff and quality).
   • Centers for Medicare & Medicaid Services (CMS) conditions of participation/coverage, as applicable.
   • Applicable Oklahoma statutes and regulations governing scope of practice and licensure.
   • Any accreditation or PCMH standards used by the health center (e.g., NCQA PCMH, The Joint Commission, URAC, if applicable).

4. Data Management and Recordkeeping

   • Maintain accurate, organized, and up-to-date electronic and/or paper provider payer credentialing files in accordance with organizational policies, HRSA expectations, applicable privacy and confidentiality requirements (e.g., HIPAA for any protected health information inadvertently included), and applicable state law record-retention rules.
   • Enter and maintain provider data in credentialing software or databases; generate reports on credentialing status, expirable, and compliance metrics.
   • Assist leadership with reporting necessary for HRSA operational site visits, quality improvement, risk management, and board or committee review.

5. Coordination, Communication, and Training

   • Communicate clearly with Medical Staff Coordinator about documentation requirements, timelines, and any deficiencies in payer credentialing files.
   • Collaborate with appropriate staff to ensure coordinated onboarding and compliance with payer requirements.

6. Quality Improvement and Risk Management Support

   • Assist in quality assurance/quality improvement efforts related to provider credentialing and privilege.
   • Help identify trends or process gaps that may impact patient safety, compliance, or reimbursement (e.g., recurring delays in obtaining verifications or enrollments)

7. Other Duties

   • Perform other duties related to payer credentialing, privileging, provider enrollment, and provider data management as assigned by management.
   • Maintain strict confidentiality of all provider and organizational information consistent with policy and law.

ORGANIZATION:

• Exhibits enthusiasm, a positive attitude, and professionalism in the workplace
• Handles personal conflict and works through it at the lowest possible level (first with party/parties involved, then, if necessary, with 3rd party mediation)
• Displays a friendly manner and is easy to approach
• Maintains a neat, clean, well-groomed, appearance and dresses in accordance with the dress code policy
• Leaves personal problems out of the workplace
• Treats all co-workers with dignity and respect
• Abstains from gossip in the workplace
• Arrives on time and work through designated hours
• Completes tasks effectively, accurately and on time
• Demonstrates little or no absenteeism/follows leave guidelines
• Follows designated line of support
• Display a willingness and flexibility to respond to unusual job-related demands
• Manages time well
• Recognizes and assists others in the work of the department, even though the work may be outside of regular duty.
• Shares equally in the workload of the department
• Works cooperatively with all team members and departments
• Works independently requesting assistance from supervisor only as needed
• Abstains from criticizing COFMC, colleagues and supervisors
• Demonstrate loyalty to COFMC, colleagues and supervisors
• Demonstrates support of the mission and vision of COFMC
• Accepts and participates in cross training
• Takes initiative to identify skill development needs
• Commitment to the mission of COFMC.