Credentialing Specialist

Credentialing Specialist

The Credentialing Specialist is responsible for coordinating and maintaining all activities related to credentialing, recredentialing, licensure verification, board certification tracking, and provider privileging for providers and licensed clinical staff. This position ensures compliance with Health Resources and Services Administration (HRSA), Centers for Medicare & Medicaid Services (CMS), state licensing boards, accreditation standards, payer requirements, and organizational policies. The role serves as the central point of contact for credentialing activities and maintains accurate provider records throughout the employment lifecycle.

This position does not perform payer enrollment, provider billing, or revenue cycle management functions.

A Day in the Life

This job description reflects management's assignment of essential functions. Nothing in this job description restricts management's right to assign or reassign duties and responsibilities to this job at any time.

Credentialing and Recredentialing

· Coordinates initial credentialing and recredentialing activities for all licensed clinical personnel, including: Physicians, Nurse Practitioners, Physician Assistants, Pharmacists, Behavioral Health Providers, Registered Nurses, Licensed Practical Nurses, Licensed Clinical Social Workers, Counselors and Therapists, Medical Assistants, Dental Assistants, Pharmacy Technicians and other licensed healthcare professionals as assigned.

· Conducts primary source verification for licenses, educational credentials, training and residency completion, board certifications, DEA registrations, National Provider Identifier (NPI) information, OIG, SAM, NPDB, professional references, and sanctions & exclusions.

· Maintains complete and accurate credentialing files in accordance with regulatory requirements.

License and Certification Management

· Monitors expiration dates for professional licenses, certifications, BLS certifications, and other required credentials.

· Provides timely notifications to employees and leadership regarding upcoming expirations.

· Ensures all licensed personnel maintain active and unrestricted credentials as a condition of employment.

· Escalates credentialing deficiencies or lapses to leadership immediately.

Board Credentialing

· Completes credentialing checklists for providers and clinical staff in a timely manner before the board cycle.

· Retains detailed and accurate records in a standardized format for all clinical staff.

· Maintains knowledge of all HRSA and FTCA credentialing and privileging requirements.

· Tracks license and certification expirations for all providers and clinical staff to ensure timely renewals.

· Assists providers and other staff as necessary with the completion of applications and credentialing paperwork, including gathering appropriate signatures.

· Works collaboratively with HR to ensure necessary documents are collected during orientation and before, if applicable.

· Maintains confidentiality of provider and staff information.

Regulatory Compliance, Record Management and Reporting

· Conducts periodic audits of credentialing files.

· Assists during external audits, surveys, and accreditation reviews.

· Generates reports as needed regarding credentialing status, expiring licenses, recredentialing activities and audit findings.

· Maintains credentialing databases and tracking systems.

Core Competencies

Customer Service: Committed to increasing customer satisfaction, sets proper customer expectations, assumes responsibility for solving customer problems, ensures commitments to customers are met.

Communication: Understand and communicate effectively with others using a variety of contexts and formats, which include writing, speaking, reading, listening and interpersonal skills.

Dependability: Meets commitments, works independently, accepts accountability, handles change, sets personal standards, stays focused under pressure, meets attendance/punctuality requirements.

Quality: Is attentive to detail and accuracy, is committed to excellence, looks for improvements continuously, monitors quality levels, finds root cause of quality problems, owns/acts on quality problems. Strong organizational and project management skills are essential.

Productivity: Manages a fair workload, volunteers for additional work, prioritizes tasks, develops good work procedures, manages time well, and handles information flow.

Success Requirements

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Education/Experience

· High school diploma or GED minimum. Associate degree or higher preferred.

· Minimum of 2 years or more relevant healthcare credentialing experience is strongly preferred.

· Experience working in an FQHC hospital, medical group, or healthcare organization is preferred.

Language Skills

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Reasoning Ability

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills

To perform this job successfully, an individual should have the ability to gain knowledge of current practice management system, electronic medical record, Microsoft Word, text paging, Internet, and Intranet.

Certificates, Licenses, Registrations

Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management is preferred.

Other Applicable Requirements

Maintains confidentiality of all personnel, medical, financial, or other sensitive materials and information in printed, electronic, or verbal form, which may jeopardize the privacy of patients and/or employees. Accesses and uses the minimum necessary patient identifiable information to perform job responsibilities and only for authorized purposes.

Physical Demands

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to stand; walk; use hands to finger, handle, or feel; reach with hands and arms and talk or hear. The employee is occasionally required to sit and stoop, kneel, crouch, or crawl. The employee must regularly lift and /or move up to 25 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception, and ability to adjust focus.

Work Environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this Job, the employee are occasionally exposed to fumes or airborne particles, toxic or caustic chemicals and risk of radiation. The noise level in the work environment is usually moderate.

EEO Statement

It is the policy of Primary Health Solutions to provide equal employment opportunities without regard to race, color, religion, sex, national origin, age, disability, marital status, veteran status, sexual orientation, genetic information, or any other protected characteristic under applicable law.

Other Duties

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities, and activities may change at any time with or without notice