Credentialing Coordinator

Job Description
Credentialing Coordinator

Position Summary

The Credentialing Lead is responsible for overseeing and executing complex provider credentialing activities across multiple states and payer networks. This role serves as the subject matter expert for escalated credentialing issues, ensures regulatory and accreditation compliance, manages provider credential expirations, and drives operational excellence within the credentialing function. The Credentialing Lead owns the credentialing work queue, prioritizes high-risk and time-sensitive cases, and partners closely with providers, payers, licensing boards, and internal stakeholders to ensure timely enrollment and ongoing compliance.

Key Responsibilities

Credentialing Operations

• Manageand maintain ownership of the credentialing and recredentialing workqueue, ensuring timely processing and resolution of cases.
• Handlecomplex credentialing scenarios, including multi-state licensure, payerenrollment challenges, provider relocations, and high-priority onboardingcases.
• Coordinateand submit credentialing applications to commercial, government, andmanaged care payers.
• Monitorcredentialing status and proactively address delays, deficiencies, orbarriers to enrollment.

Escalation Management

• Serveas the primary escalation point for credentialing-related issues.
• Investigateand resolve complex credentialing and enrollment problems with payers,providers, and regulatory agencies.
• Developcorrective action plans and drive issues through resolution whilemaintaining stakeholder communication.

Expiration & Compliance Management

• Overseetracking and management of provider licenses, certifications,registrations, malpractice insurance, and other credentialingrequirements.
• Ensuretimely renewals and prevent lapses that could impact provider eligibilityor reimbursement.
• Maintainaccurate credentialing records and documentation in credentialing systemsand databases.

Accreditation & Quality Oversight

• Maintaincredentialing processes in accordance with accreditation standards.
• Supportaudits, accreditation reviews, and internal quality assurance initiatives.
• Ensurecredentialing policies, procedures, and documentation remain compliantwith regulatory and accreditation requirements.
• Identifyprocess improvement opportunities and implement best practices tostrengthen compliance and operational efficiency.

Leadership & Collaboration

• Provideguidance and mentorship to credentialing specialists and team members.
• Establishand monitor credentialing performance metrics, service levels, and qualitystandards.
• Collaboratewith Provider Operations, Compliance, Revenue Cycle, Clinical Leadership,and external partners to support organizational goals.
• Assistin developing workflows, training materials, and standard operatingprocedures.

Qualifications

Required

• 3+years of provider credentialing experience, including payer enrollment andrecredentialing.
• Demonstratedexperience managing complex credentialing cases and multi-state providercredentials.
• Strongunderstanding of credentialing regulations, payer requirements, andprovider enrollment processes.
• Experienceworking with credentialing software, CAQH, NPPES, PECOS, and statelicensing boards.
• Knowledgeof accreditation standards such as NCQA, URAC, or Joint Commission.
• Excellentorganizational, problem-solving, and communication skills.
• Abilityto manage multiple priorities in a fast-paced environment.

Preferred

• CertifiedProvider Credentialing Specialist (CPCS) certification.
• Experienceleading credentialing operations or serving as a team lead.
• Experiencesupporting multi-state healthcare organizations.
• Advancedreporting and process improvement experience.

Success Measures

• Credentialingand enrollment turnaround times meet or exceed organizational goals.
• Providercredential expirations are proactively managed with minimal to no lapses.
• Escalatedcredentialing issues are resolved efficiently and effectively.
• Accreditationand audit requirements are consistently met.
• Credentialingqueue remains current and within established service level agreements.
• Highlevels of provider and internal stakeholder satisfaction.

Reports To: Director of Provider Relations and Credentialing


Classification: Full-Time

Department: Provider Network Operations / Credentialing & Enrollment

Requirements
Education

• High school diploma or GED required
• Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or related field preferred

Experience

• 3+ years of provider credentialing or medical staff services experience preferred
• Experience with payer enrollment and provider credentialing processes
• Knowledge of commercial, Medicare, and Medicaid enrollment requirements
• Experience working in a healthcare organization, provider network, or health plan preferred

Required Knowledge

• Provider credentialing and re-credentialing processes
• Primary Source Verification (PSV)
• CAQH ProView maintenance
• NPI and PECOS enrollment
• Medicare, Medicaid, and commercial payer enrollment
• NCQA, CMS, Joint Commission, and state regulatory requirements
• Provider file maintenance and document management
• Medical terminology and healthcare operations

Technical Skills

• Microsoft Office (Excel, Word, Outlook)
• Credentialing software
• Electronic document management systems
• Database management and accurate data entry
• Internet research and state licensing board websites

Core Competencies

• Exceptional attention to detail
• Strong organizational skills
• Time management and prioritization
• Excellent written and verbal communication
• Customer service orientation
• Problem-solving and critical thinking
• Ability to manage multiple deadlines
• Ability to work independently and collaboratively
• Confidentiality and professionalism

Benefits

Health Insurance

Dental Insurance

Vision Insurance

Paid Time Off (PTO)

Employee Assistance Program (EAP)

401(k) with Employer Contribution

Health Savings Account (HSA)

Flexible Savings Account (FSA)

Referral Program

Life Insurance

Discounted Gym Membership