Credentialing Specialist

Credentialing SpecialistResponsible for performing day-to-day credentialing, recredentialing, licensing, privileging, and payer enrollment activities for Premier and Philadelphia Hand to Shoulder Center physicians and other healthcare providers. Ensures credentialing applications and supporting documentation are complete, accurate, and submitted within required timeframes. Maintains current provider information within credentialing systems, monitors licenses, certifications, and other expirable credentials, and provides timely follow-up with physicians/providers, hospitals, health plans, and other organizations. Works closely with the Credentialing Manager and internal departments to support timely provider onboarding and maintain ongoing credentialing compliance.Essential FunctionsCompletes and processes initial credentialing and recredentialing applications for physicians and other healthcare providers.Collects, reviews, and maintains required credentialing documentation, including professional licenses, board certifications, DEA registrations, professional liability insurance, education, training, work history, and other required credentials.Performs primary source verification of provider credentials in accordance with applicable requirements.Obtains and reviews National Practitioner Data Bank (NPDB), Office of Inspector General (OIG), state licensing board, and other applicable verification or sanction information.Completes and maintains provider enrollment applications for Medicare, Medicaid, commercial health plans, and other applicable payers.Coordinates hospital and facility credentialing, privileging, and reappointment applications, as applicable.Maintains accurate and current provider information within CAQH and other applicable credentialing, payer, hospital, and provider databases.Tracks and monitors provider licenses, DEA registrations, board certifications, professional liability insurance, and other expirable credentials to ensure timely renewal.Contacts physicians/providers to obtain outstanding applications, signatures, attestations, documentation, and other information required to complete credentialing activities.Provides consistent and timely follow-up on outstanding credentialing and recredentialing applications.Communicates credentialing status, outstanding requirements, and potential delays to the Credentialing Manager and other appropriate stakeholders.Identifies incomplete, inconsistent, or potentially concerning credentialing information and escalates issues to the Credentialing Manager for review.Ensures hospitals, health plans, medical groups, and other applicable entities receive required provider demographic and practice updates.Processes provider demographic changes, additions, terminations, and other updates with applicable payers, hospitals, facilities, and credentialing organizations.Assists with provider network termination activities when providers leave the organization.Maintains accurate electronic credentialing files and ensures documentation is appropriately filed, scanned, indexed, and entered into applicable credentialing systems.Ensures provider credentialing records are complete, accurate, current, confidential, and audit-ready.Monitors credentialing and enrollment timelines and follows up with payers, hospitals, and other entities regarding pending applications.Assists with researching and resolving credentialing and payer enrollment issues that may impact provider billing or reimbursement.Partners with Revenue Cycle Management to research credentialing-related claim denials and provider enrollment discrepancies as directed.Supports the provider onboarding process by completing credentialing activities within established timelines and communicating potential barriers or delays.Responds to credentialing verification requests and requests for provider documentation in accordance with organizational procedures.Assists with internal and external credentialing audits and provides requested documentation.Maintains the privacy and confidentiality of provider professional and personal information obtained in the performance of job responsibilities.Cross-trains on credentialing functions and provides back-up support to other members of the Credentialing Department as needed.Establishes and maintains effective communication with physicians/providers, hospitals, health plans, credentialing agencies, and internal departments.Participates in department meetings, training, process improvement initiatives, and special projects as requested.Performs other duties as assigned.EducationHigh school diploma or GED preferred.Associate's or bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred.Certified Provider Credentialing Specialist (CPCS) certification preferred.ExperienceMinimum of two (2) years of experience in healthcare credentialing, provider enrollment, medical staff services, or a related healthcare administrative function preferred.Experience processing physician and other healthcare provider credentialing and recredentialing applications preferred.Experience with payer enrollment, CAQH, Medicare, Medicaid, and commercial health plans preferred.Experience working in a physician practice, medical group, hospital, or outpatient healthcare organization preferred.KnowledgeKnowledge of provider credentialing and recredentialing processes.Knowledge of credentialing documentation and primary source verification requirements.Knowledge of professional licensing, DEA registration, board certification, professional liability insurance, and other provider credential requirements.Knowledge of provider enrollment processes and payer requirements.Knowledge of CAQH and applicable governmental and commercial payer enrollment systems.Knowledge of credentialing timelines and provider expirable requirements.Knowledge of NPDB, OIG, state licensing board, and other applicable credentialing verification resources.Knowledge of credentialing databases and Microsoft Office applications.SkillsExcellent organizational and time-management skills.Strong attention to detail and accuracy.Excellent verbal and written communication skills.Skill in managing multiple credentialing files, applications, and deadlines simultaneously.Skill in reviewing documentation for accuracy and completeness.Skill in identifying missing or inconsistent credentialing information.Skill in following up effectively with physicians/providers and external organizations.Strong data entry and record-maintenance skills.Strong problem-solving skills.Skill in establishing effective working relationships with physicians/providers, staff, payers, hospitals, and credentialing agencies.Skill in maintaining confidentiality and handling sensitive information appropriately.AbilitiesAbility to independently process credentialing and recredentialing applications from initiation through completion.Ability to manage multiple provider files and competing deadlines.Ability to accurately collect, verify, enter, and maintain detailed provider information.Ability to follow established credentialing policies, procedures, and regulatory requirements.Ability to identify credentialing deficiencies or delays and escalate concerns appropriately.Ability to communicate professionally and effectively with physicians/providers, hospitals, payers, credentialing agencies, management, and staff.Ability to organize and prioritize work to meet credentialing, enrollment, and renewal deadlines.Ability to exercise sound judgment and maintain strict confidentiality.Ability to work effectively both independently and as part of the Credentialing Department.Environmental Working ConditionsNormal office and healthcare administrative environment.Occasional travel between Premier and Philadelphia Hand to Shoulder Center locations as needed.Physical/Mental DemandsRequires sitting, standing, walking, and occasional bending associated with a normal office environment.Requires manual dexterity for computer, telephone, and other office equipment use.Requires sustained attention to detail and accuracy when reviewing and entering provider credentialing information.Requires the ability to manage multiple priorities and time-sensitive credentialing deadlines.Organizational RequirementsHOPCo's Mission, Vision, and Values must be acknowledged and adhered to.Completes all required organizational training and education.Maintains compliance with all policies and procedures.Equal Opportunity Employer This employer is required to notify all applicants of their rights pursuant to federal employment laws. For further information, please review the Know Your Rights notice from the Department of Labor.