Credentialing Specialist

Credentialing Specialist

The Credentialing Specialist is responsible for the timely and accurate credentialing, re-credentialing, and payer enrollment of all Phoenix Heart providers, including physicians and advanced practice providers (APPs), across all practice locations. This role ensures providers maintain active hospital privileges, payer participation, and compliance with regulatory, accreditation, and health plan requirements.

The Credentialing Specialist works closely with the Revenue Cycle Manager, Human Resources, physician partners, practice administration, and external payers and hospitals to prevent lapses in credentialing status that could affect patient care or reimbursement.

Credentialing and Enrollment

• Manage the end-to-end credentialing and re-credentialing process for all physicians and APPs, including primary source verification of licensure, education, training, board certification, DEA registration, malpractice history, and work history.
• Complete and submit payer enrollment applications, including Medicare, Medicaid, and commercial insurance plans, and track applications through approval.
• Maintain and regularly update CAQH profiles for all providers, ensuring attestations remain current.
• Coordinate hospital privileging applications and renewals for providers requiring admitting or procedural privileges at partner facilities.

Tracking and Compliance

• Maintain a master credentialing tracker with expiration dates for licenses, DEA registrations, board certifications, malpractice coverage, and payer contracts, proactively flagging upcoming renewals.
• Ensure compliance with NCQA, CMS, and state credentialing standards, as well as payer-specific requirements.
• Maintain accurate, audit-ready credentialing files for each provider in accordance with practice policy and applicable regulations.
• Respond to payer, hospital, and internal audits or requests for credentialing documentation.

Onboarding and Communication

• Partner with the HR Generalist on new provider onboarding, ensuring credentialing begins immediately upon offer acceptance so start dates are not delayed.
• Communicate proactively with providers regarding documentation needed to complete or renew credentialing.
• Monitor and report on credentialing status and upcoming deadlines to the Human Resources and practice leadership.

Confidentiality and Additional Duties

• Maintain confidentiality of provider records in accordance with HIPAA and Phoenix Heart policy.
• Support other HR and administrative projects as needed.

Requirements

Qualifications and Experience

• Minimum of two years of experience in medical staff credentialing, payer enrollment, or provider onboarding, preferably in a physician practice, hospital, or health system setting.
• Working knowledge of NCQA standards, CMS requirements, and commercial payer credentialing processes.
• Experience with CAQH, PECOS, and payer enrollment portals.
• Healthcare, medical practice, or ambulatory care experience required.

Education and Certifications

• High school diploma or equivalent required.
• Associate's or Bachelor's degree preferred.
• Certified Provider Credentialing Specialist (CPCS) certification through NAMSS preferred but not required.

Knowledge, Skills, and Abilities

• Strong organizational skills and attention to detail, with the ability to manage multiple deadline-driven files simultaneously.
• Familiarity with credentialing or provider data management software preferred.
• Proficiency in Microsoft Office, including Excel, Word, and Outlook.
• Excellent written and verbal communication skills in English.
• Ability to maintain strict confidentiality of sensitive provider and patient information.
• Ability to work independently while following established workflows and supervision.

Physical and Work Environment Requirements

• Prolonged periods of sitting and computer use.
• Primarily an office-based role; occasional travel between Phoenix Heart locations may be required.
• Reasonable accommodations may be made to enable individuals with disabilities to perform essential functions.

Compliance Statement

Phoenix Heart is an Equal Opportunity Employer. Job duties may be modified as business needs evolve.