Credentialing Specialist

Job Type


Full-time

Description

Credentialing Specialist

Position Summary:

The Credentialing Specialist is responsible for managing and coordinating the credentialing, re-credentialing, payer enrollment, facility privileging, licensure, and ongoing credentialing compliance processes for Iowa Ortho physicians, physician associates (PAs), nurse practitioners (NPs), and radiologists.

This position serves as a primary resource for providers and works closely with the HR Director, Executive Administrative team, providers, insurance payers, hospitals, surgery centers, and other external organizations to ensure all credentialing requirements are completed accurately and within required timelines.

The Credentialing Specialist maintains confidential and highly detailed provider records, monitors regulatory and credentialing requirements, and ensures providers remain appropriately credentialed and eligible to practice and participate with applicable payers and facilities.

Requirements

Key Responsibilities

Credentialing & Re-Credentialing:

• Manage the complete credentialing and re-credentialing process for Iowa Ortho physicians, PAs, NPs, and radiologists, from initial application through final approval.
• Prepare, complete, submit, and track credentialing and re-credentialing applications and supporting documentation.
• Coordinate directly with providers to obtain required information, documentation, signatures, and attestations.
• Monitor application status and proactively follow up with payers, hospitals, facilities, and other credentialing entities to ensure timely completion.
• Maintain accurate, organized, confidential, and audit-ready credentialing files and provider records.
• Ensure provider information remains current and consistent across credentialing systems and external databases.

Payer Enrollment:

• Manage provider enrollment and participation with commercial insurance plans, government payers, and other applicable health plans.
• Complete and submit payer enrollment applications, updates, revalidations, demographic changes, and other required documentation.
• Monitor enrollment status and follow up with payers to resolve outstanding items, discrepancies, or delays.
• Coordinate provider additions, terminations, address changes, specialty updates, and other payer-related changes as needed.

Hospital & Facility Privileging:

• Coordinate initial and ongoing hospital, surgery center, and other facility privileging for applicable providers.
• Prepare and submit privilege applications, reappointments, supporting documentation, and other required materials.
• Track privilege status, expiration dates, and reappointment requirements.
• Communicate with hospitals and facilities to address missing information, application questions, and other credentialing requirements.

CAQH & Provider Databases:

• Create, maintain, and manage provider profiles in CAQH and other required credentialing databases.
• Complete and monitor CAQH attestations and ensure provider information remains accurate and current.
• Maintain provider information in payer portals, hospital and facility systems, and other applicable credentialing platforms.
• Utilize Iowa Ortho's internal systems, including RFX and Modio, as well as NextGen and other credentialing and provider-management systems.

Licensure, Certifications & Compliance:

• Monitor and maintain provider licenses, DEA registrations, controlled substance registrations, certifications, continuing education requirements, and other professional credentials.
• Maintain accurate tracking systems for expiration dates, renewal deadlines, and required documentation.
• Coordinate and follow up on renewals to ensure credentials remain current and providers remain compliant with applicable requirements.
• Track continuing education and other professional requirements as applicable to provider licensure, organizational policies, and credentialing standards.
• Maintain awareness of changes to licensing, credentialing, payer, and regulatory requirements that may affect Iowa Ortho providers.
• Identify potential credentialing or compliance issues proactively and communicate concerns to the appropriate internal leaders.

Provider Onboarding & Ongoing Support:

• Coordinate credentialing requirements for new physicians, PAs, NPs, and radiologists and ensure applications, licenses, enrollments, privileges, and required documentation are completed prior to the provider's start date whenever possible.
• Serve as a primary point of contact for providers regarding credentialing, payer enrollment, privileging, licensure, and related requirements.
• Communicate credentialing timelines, outstanding requirements, and action items to providers and appropriate internal departments.
• Collaborate closely with the Executive Administrative team to coordinate provider onboarding and ensure credentialing, enrollment, licensure, privileging, and other administrative requirements are completed in alignment with provider start dates.
• Respond to credentialing-related questions and provide guidance regarding required documentation and processes.

Records & Administrative Support:

• Maintain accurate, confidential, and audit-ready credentialing records and documentation.
• Develop and maintain credentialing trackers, calendars, and systems to monitor deadlines and outstanding requirements.
• Ensure timely completion of credentialing-related data entry, documentation, and file management.
• Assist with internal and external credentialing audits and provide requested documentation as needed.
• Protect confidential provider and organizational information and exercise sound judgment when handling sensitive information.
• Work independently to prioritize multiple deadlines, follow established processes, and manage competing priorities.
• Work collaboratively with the HR Director and Executive Administrative team to ensure effective communication and coordination of provider-related administrative needs.

Qualifications:

• Prior credentialing experience required; experience with provider credentialing, payer enrollment, and facility privileging strongly preferred.
• Prior healthcare administrative experience required.
• Experience working with CAQH, payer portals, hospital and facility credentialing systems, and provider licensing systems preferred.
• High school diploma or equivalent required; associate or bachelor's degree in healthcare administration, business, or a related field preferred.
• Strong attention to detail and exceptional organizational and time-management skills.
• Ability to manage multiple providers, applications, deadlines, and priorities simultaneously.
• Strong written and verbal communication skills with the ability to communicate professionally with providers, payers, hospitals, facilities, and internal departments.
• Ability to work independently, exercise sound judgment, and take ownership of assigned responsibilities.
• Ability to maintain confidentiality and handle sensitive information appropriately.
• Strong problem-solving, follow-up, and communication skills.
• Proficiency with Microsoft Office Suite, including Word, Excel, and Outlook.
• Ability to learn and effectively utilize credentialing, payer, licensing, and healthcare information systems.

Why Choose Iowa Ortho? At Iowa Ortho, we are guided by our IMPACT values , and we believe in fostering a culture that prioritizes both professional excellence and compassionate care:

• Innovation that Drives Positive Outcomes (I)
• Motivation for Exceptional Care (M)
• Passion for Quality in Everything We Do (P)
• Accountability Through Open and Honest Communication (A)
• Commitment to Continued Growth (C)
• Teamwork (T)

Please note that our first point of contact may be by email. Please check your spam or junk folder, as messages from unknown senders may occasionally be filtered. Iowa Ortho is a privately held medical practice. Candidates who receive a conditional offer of employment at Iowa Ortho will be required to complete a criminal background check, education verification, reference checks, and an initial TB test. Iowa Ortho is committed to a diverse and inclusive workplace. Iowa Ortho is an equal opportunity employer and does not discriminate on the basis of race, national origin, gender, gender identity, sexual orientation, protected veteran status, disability, age, or other legally protected status.