Internal Credentialing Specialist

Position Summary

The Internal Credentialing Specialist is responsible for coordinating and managing the organization's internal credentialing, recredentialing, privileging, and provider compliance processes for licensed healthcare professionals. This position ensures compliance with organizational policies, HRSA requirements, and regulatory guidelines through the verification, maintenance, and monitoring of provider credentials and privileging records. The specialist also maintains cross-training competency in payer enrollment functions to support departmental continuity, collaboration, and operational efficiency.

Essential Functions

The following duties are fundamental to the position:

Provider Credentialing Administration

• Collect and maintain credentialing applications, privileges requests, and supporting documentation from new and existing providers..
• Coordinate initial credentialing and recredentialing processes for practitioners and allied health professionals.
• Conduct primary source verification of all required information including licenses, certifications, education and professional references as required.
• Collect Privileges requests and facilitate updates as needed.
• Monitor credentialing and recredentialing deadlines to ensure approvals are updated according to regulatory requirements.
• Maintain electronic credentialing records, credentialing databases and tracking systems, ensuring all records are. complete, accurate, and current.
• Prepare credentialing packets for Risk Management committee review and approval.
• Communicate credentialing and re-credentialing decisions to providers and internal stakeholders.
• Verify completion of all required credentialing documentation and Risk Management Committee approval before clinical services begin.

Records Maintenance

• Maintain accurate records of provider credentialing status and answer questions from leadership regarding status
• Maintain privilege forms for all clinical categories (i.e. family practice, OB, Behavioral Health) and make changes as requested by the CMO.
• Work with the Medical Staff Coordinator to update privileges if Supervising Physician changes.
• Monitor expiration dates for licenses, certifications, registrations, and other credentials, and obtain updated documents from providers and others as applicable.
• Monitor sanctions, exclusions, and disciplinary actions through CA Breeze and NPDB.

Internal Consultation and Process Improvement

• Serve as a resource regarding credentialing policies and procedures.
• Provide guidance to providers and department managers on credentialing requirements.
• Recommend process improvements and workflow efficiency updates
• Assist with developing and updating credentialing policies and procedures.
• Assist providers with obtaining malpractice coverage verification.

Minimum Qualifications

Education

• High School Diploma

Experience

• Minimum two (2) years of experience in credentialing, healthcare administration, medical staff services, compliance, provider services, human resources, physician office, FQHC, ambulatory surgery center, hospital, or related healthcare setting.
• Experience with credentialing, privileging, provider verification, or compliance processes preferred.

Knowledge

• Strong knowledge of Microsoft Office Word, Excel, and Outlook.
• Knowledge of provider credentialing and recredentialing practices.
• Knowledge of primary source verification requirements.
• Knowledge of credentialing databases and recordkeeping systems.
• Knowledge of confidentiality and HIPAA requirements related to provider records.

Skills

• Strong organizational skills with the ability to manage multiple priorities and deadlines.

• Maintains confidentiality regarding sensitive provider and organizational information.

• Demonstrates excellent customer service and interpersonal communication skills.

• Skill in maintaining accurate records and databases.

• Skill in organizing and prioritizing multiple projects and deadlines.

• Skill in preparing reports, credentialing packets, and correspondence.

• Skill in researching and resolving discrepancies in provider records.

• Skill in verbal and written communication.

• Skill in customer service and stakeholder support.

Abilities

• Communicates effectively using welcoming words, proper tone of voice, appropriate body language, eye contact, and professionalism in every interaction.

• Ability to establish and maintain positive working relationships with employees, providers, leadership, and the public.

• Ability to provide excellent customer service reflective of a culture that values trust and respect.

• Ability to interpret and apply policies, procedures, and regulations.

• Ability to analyze information and identify missing or incomplete documentation.

• Ability to manage multiple deadlines and competing priorities.

• Ability to exercise independent judgment within established guidelines.

• Ability to communicate effectively with providers, leadership, and staff.

• Ability to prepare accurate and complete credentialing records.

• Ability to identify compliance concerns and escalate issues appropriately.

• Ability to establish and maintain effective working relationships.

Competencies

In addition to Peach Tree Healthcare's company values, this role will be assessed on the following competencies:

Credentialing Knowledge:

• Coordinating initial and recredentialing processes.

• Understanding credentialing documentation requirements.

• Managing provider privilege requests and approvals.

• Applying credentialing standards consistently.

• Maintaining compliance with health center credentialing requirements.

Regulatory Compliance:

• Monitoring credentialing and recredentialing deadlines.

• Tracking license, certification, and registration expirations.

• Conducting sanction and exclusion monitoring.

• Ensuring providers are fully approved before patient care activities begin.

• Maintaining audit-ready credentialing records.

Verification and Quality Assurance:

• Conducting primary source verification.

• Reviewing provider applications for completeness and accuracy.

• Identifying discrepancies or missing documentation.

• Maintaining accurate provider status records.

• Ensuring data integrity within credentialing systems.

Attention to Detail:

• Detecting incomplete applications.

• Tracking renewal deadlines.

• Monitoring changes in provider status.

• Maintaining complete credentialing files.

• Accurately preparing committee packets.

Organization and Time Management:

• Managing large volumes of provider records.

• Coordinating recredentialing schedules.

• Tracking expiration and renewal requirements.

• Prioritizing urgent credentialing needs.

• Meeting committee and onboarding timelines.

Analytical and Problem-Solving Skills:

• Researching discrepancies in credentialing documentation.

• Resolving incomplete application issues.

• Identifying compliance risks.

• Evaluating process improvement opportunities.

• Escalating complex matters with appropriate recommendations.

Customer Service and Relationship Management:

• Assisting providers through the credentialing process.

• Responding promptly to requests for information.

• Serving as a resource on credentialing procedures.

• Building effective working relationships with providers and managers.

Tools, Technology, and Equipment: The following tools and equipment are commonly used to perform the essential functions of this position. The tools and equipment listed are representative of those used in this position. Reasonable accommodation may be provided to enable qualified individuals with disabilities to use required tools and perform essential functions.

• Tools: Calculator, Computer and Keyboard, Multi-line Telephone, general office equipment
• Technology: NextGen or equivalent Practice Management/EHR System, Credentialing and Enrollment Databases, Microsoft Office Suite (Word, Excel, Outlook), Electronic Mail Systems

Working Conditions

Work is generally performed in a professional office environment and requires frequent use of computers, telephones, payer portals, and electronic enrollment systems. The position requires regular interaction with providers, pharmacists, payers, PBMs, leadership, and staff while maintaining professionalism, accuracy, confidentiality, and excellent customer service.

• Work is primarily performed in a standard office environment.

• Duties are performed using a computer, telephone, and other standard office equipment for extended periods of time.

• Requires prolonged sitting, standing, walking, bending, reaching, and repetitive hand and wrist movements associated with keyboard use.

• Frequent use of a computer and visual concentration for reviewing electronic records, applications, reports, and supporting documentation.

• May require occasional attendance at committee meetings or training sessions.

• Must maintain accuracy and attention to detail while working in a deadline-driven environment.

• Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of the position.

Physical Demands: The physical demands described here are representative of those required to perform the essential functions of this position. Reasonable accommodation will be considered to enable qualified individuals with disabilities to perform these functions.

• Ability to read detailed documents and view computer screens.

• Ability to communicate effectively in person, in writing and by telephone.

• Ability to sit, stand, walk, bend, stoop, and move throughout the workday.

• Manual dexterity sufficient to operate computers, telephones, and office equipment.

• Ability to sit for extended periods while performing computer-based work.

• Occasionally lift, move, or assist in lifting or moving items up to 15 pounds.

• Ability to occasionally lift and carry files, records, or office materials weighing up to 15 pounds.

• Ability to read and review detailed information on paper and computer screens.

EEO Statement

Peach Tree Healthcare is an Equal Opportunity Employer and does not discriminate in employment opportunities or practices on the basis of any characteristic protected by federal, state, or local law. The organization is committed to providing reasonable accommodations to qualified individuals with disabilities and to employees with sincerely held religious beliefs.