Credentialing Specialist

Job Description

We are seeking a detail-oriented Credentialing Specialist to serve as a vital component of our home office team. This role will be responsible for obtaining, verifying, and maintaining the credentials, licensure, and insurance coverage for our clinical staff in Texas and Oklahoma. By ensuring accurate and timely credentialing, you will directly support the revenue cycle, minimize billing disruptions, and ensure our providers are able to serve their communities.

Key Responsibilities

• Database Management: Create and maintain comprehensive digital records of provider licensing, credentials, and malpractice insurance. Manage provider profiles in industry databases (e.g., CAQH, PECOS, NPPES) with high accuracy.

• Proactive Compliance: Monitor expiration dates for licenses, DEA certificates, board certifications, and insurance policies. Issue "renew by" notifications to staff and management well in advance to prevent coverage lapses.

• Verification Liaison: Act as the primary point of contact for external agencies, hospitals, and commercial payers requesting verification of provider information.

• Regulatory Research: Stay current on updated state, federal, and payer-specific regulations (including NCQA and CMS standards) to ensure organizational policies remain compliant.

• Process Optimization: Assist in developing and revising internal credentialing Standard Operating Procedures (SOPs) to improve workflow efficiency and data integrity.

• Audit Readiness: Ensure the facility and all staff members maintain continuous compliance to ensure readiness for internal or external audits at any time.

Qualifications:
Qualifications

• Required: High School Diploma or GED. Bachelor’s degree or college coursework in Health Administration, Business, or a related field.

• Preferred: Minimum of 2 years of experience in medical billing, credentialing, provider enrollment, or medical office administration.

• Proficiency with provider enrollment platforms (Medicare, Medicaid, Commercial Payers).

• Strong knowledge of medical credentialing policies, healthcare regulations, and accreditation standards.

• Exceptional accuracy in data entry and document verification.

• Communicator: Strong verbal and written communication skills, with the ability to speak professionally with clinicians and insurance representatives.

• Organizer: Ability to meet strict deadlines and prioritize tasks in a fast-paced environment without compromising quality.

• Team Player: Willingness to collaborate with the billing and authorization teams while possessing the self-discipline to work independently.