Credentialing Specialist

The Credentialing Specialist is responsible for managing the credentialing, enrollment, recredentialing, and provider onboarding processes for physicians and advanced practice providers across multiple healthcare entities. This role ensures compliance with federal and state regulations, payer requirements, accreditation standards, and organizational policies while supporting timely provider enrollment and revenue cycle integrity. The Credentialing Specialist serves as a key liaison between providers, payers, hospitals, and internal operational teams to facilitate efficient onboarding and maintain uninterrupted reimbursement.

Essential Functions of the Role

• Collect, verify, and maintain credentialing and enrollment documentation for physicians and advanced practice providers.
• Prepare and submit initial credentialing, recredentialing, and provider enrollment applications to commercial payers, Medicare, Medicaid, and managed care organizations.
• Maintain CAQH profiles and ensure provider data is accurate, complete, and attested within required timelines.
• Coordinate provider privileging applications and appointments with hospitals, ambulatory surgery centers, and ancillary facilities.
• Track credentialing and enrollment application statuses and proactively follow up with payers, hospitals, and delegated entities to minimize delays.
• Review provider licenses, board certifications, DEA registrations, malpractice coverage, sanctions, exclusions, and work history for compliance and completeness.
• Conduct background checks and monitor provider eligibility through applicable federal and state databases including OIG, SAM, and state exclusion lists.
• Maintain provider demographic and credentialing information within credentialing databases, payer portals, and internal tracking systems.
• Assist with provider onboarding activities including EMR access coordination, payer roster updates, and collaboration with billing and operational teams.
• Support payer contracting initiatives by maintaining provider participation records and assisting with payer roster submissions and updates.
• Generate reports related to provider enrollment, credentialing expirations, payer participation, hospital privileges, and onboarding metrics.
• Monitor expirables and ensure timely renewals for licenses, certifications, malpractice insurance, and hospital privileges.
• Collaborate with Revenue Cycle, Practice Operations, Contracting, Compliance, and Clinical Leadership teams to resolve enrollment or reimbursement issues impacting claims payment.
• Research and respond to credentialing and enrollment inquiries from providers, payers, hospitals, and internal stakeholders.
• Maintain working knowledge of payer policies, CMS guidelines, NCQA standards, Joint Commission standards, and delegated credentialing requirements.
• Participate in audits and support accreditation readiness activities.
• Identify opportunities for process improvement, workflow optimization, and standardization across credentialing and enrollment operations.
• Assist in developing and maintaining credentialing policies, procedures, and tracking tools.
• Participate in ongoing training and professional development activities related to credentialing, enrollment, and healthcare compliance.

Minimum Qualifications

• Bachelor's degree in Healthcare Administration, Business Administration, or related field preferred.
• Minimum of 2 years of experience in healthcare credentialing, provider enrollment, or related healthcare administrative role.
• Working knowledge of Medicare, Medicaid, and commercial payer enrollment processes.
• Familiarity with CAQH, PECOS, NPPES, and payer credentialing portals.
• Understanding of healthcare regulations, credentialing standards, and medical terminology.
• Strong organizational skills with exceptional attention to detail and ability to manage multiple priorities and deadlines.
• Excellent verbal and written communication skills.
• Proficiency in Microsoft Office Suite including Excel, Outlook, and Word.
• Experience working with credentialing software, provider databases, and electronic document management systems.

Desired Qualifications

• Certification from a recognized credentialing organization such as CPCS or CPMSM preferred.
• Experience supporting multi-specialty physician practices, ambulatory surgery centers, or cardiovascular service lines preferred.
• Experience with delegated credentialing or payer contracting support preferred.
• Knowledge of hospital privileging and provider onboarding workflows preferred.

Physical Requirements

This position requires full range of body motion. While performing the duties of this job, the employee is regularly required to sit, walk and stand; talk or hear, both in person and by telephone; use hands repetitively to handle or operate standard office equipment; reach with hands and arms; and lift up to 25 pounds.

Equal Employment Opportunity Statement

We provide equal employment opportunities to all employees and applicants for employment and prohibits discrimination and harassment of any type without regard to race, color, religion, age, sex, national origin, disability status, genetics, protected veteran status, sexual orientation, gender identity or expression, or any other characteristic protected by federal, state or local laws. This policy applies to all terms and conditions of employment, including recruiting, hiring, placement, promotion, termination, layoff, recall, transfer, leaves of absence, compensation and training.

The statements contained herein are intended to describe the general nature and level of work performed by the Credentialing Specialist, but are not a complete list of the responsibilities, duties, or skills required. Other duties may be assigned as business needs dictate. Reasonable accommodation may be made to enable qualified individuals with disabilities to perform the essential functions.