Job Description

Job Description

Job Description

Position Overview:

We are seeking a highly organized and detail-oriented Credentialing Specialist . This role is crucial in ensuring that healthcare providers and practitioners meet all the necessary licensing, certification, and credentialing requirements to practice within our organization and participate in insurance networks. You will be responsible for reviewing, processing, and managing the credentialing and re-credentialing process for healthcare professionals.

Key Responsibilities:

• Credentialing & Re-credentialing: Process and maintain provider credentialing files, ensuring compliance with internal policies and external regulatory requirements.
• Documentation Management: Review applications and verify qualifications, licensure, education, training, and professional experience.
• Database Maintenance: Ensure the provider database is up-to-date with accurate and complete credentialing information.
• Insurance Network Enrollment: Submit applications and maintain current information for providers in various insurance plans and networks.
• Regulatory Compliance: Ensure all credentialing processes are compliant with federal and state regulations, as well as healthcare accreditation standards.
• Communication: Act as the main point of contact for providers during the credentialing process. Communicate clearly with internal teams, providers, and insurance carriers to resolve issues promptly.
• Audit Preparation: Assist in preparing for audits related to provider credentialing.

Qualifications:

• Education: High school diploma or equivalent required; Associate's degree or higher preferred.
• Experience: At least 2 years of experience in credentialing or a related healthcare field. Experience with insurance networks and regulatory requirements is a plus.
• Knowledge: Familiarity with credentialing systems, healthcare terminology, and HIPAA compliance.
• Skills:
  • Strong attention to detail and accuracy.
  • Excellent organizational and time-management skills.
  • Proficient in MS Office Suite (Word, Excel, PowerPoint).
  • Effective verbal and written communication skills.
  • Ability to multitask and manage competing priorities in a fast-paced environment.

Preferred Qualifications:

• Certification in credentialing (e.g., CPCS, CPMSM).
• Experience with credentialing software systems.

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