Credentialing Specialist

Credentialing Specialist

The Credentialing Specialist plays a critical role in ensuring providers are credentialed, enrolled, and compliant with all applicable licensing, payer, accreditation, and regulatory requirements. This position is responsible for provider credentialing, payer and DHS enrollment, recredentialing, and ongoing compliance activities that support uninterrupted service delivery and timely reimbursement.

The Credentialing Specialist reviews and verifies provider qualifications, licenses, certifications, professional education, and other required documentation through primary source verification. This role partners closely with providers, payers, leadership, and internal stakeholders to maintain accurate records, monitor credentialing deadlines, ensure compliance with applicable requirements, and support organizational success.

This is a hybrid role based in Minnesota. 1-2 days at the corporate office in Minnetonka, MN is expected. Only considering individuals that live in Minnesota.

Hiring Pay Range: $26/hour - $31/hour

This role requires a high level of autonomy, strong attention to detail, and the ability to manage multiple complex timelines independently.

Responsibilities

Document Verification

• Review and authenticate primary source documents including state licensures, board certifications, professional work history, malpractice insurance, and other credentials to ensure accuracy and validity.
• Creating and maintaining detailed records of provider license, certifications, Early Intensive Developmental and Behavioral Intervention (EIDBI) documents, and professional degree(s) to ensure credentialing databases are up to date.

Credentialing Application Processing

• Collect and examine initial and re-credentialing applications for completeness, accuracy, and compliance with state, federal, and organizational policies.
• Communicate with providers to obtain necessary EIDBI forms, licensures, and certifications.

Data Entry and Maintenance

• Entering and updating provider data in credentialing systems to ensure accuracy, confidentiality, and audit-ready records.
• Documenting and tracking license numbers, expiration dates, and professional supervised clinical hours.

Compliance Monitoring

• Monitor license and certification renewal dates to prevent lapses, and coordinate renewals to ensure ongoing compliance with state and federal regulations.
• Staying current on Federal and MN Department of Human Services (DHS) state laws, EIDBI guidelines, and payer credentialing requirements to ensure credentialing practices adhere to regulatory and accreditation standards.
• Ensure compliance with HIPAA guidelines, Medicaid/Medicare state regulations, mental/behavioral health standards, and internal policies.

Payer Submission

• Prepare and submit credentialing applications to commercial insurance carriers (e.g. UHC, BCBS, HP, etc.), and government payers (including Medicare, Medicaid, MHCP).
• Conduct proactive follow-up with insurance payers to ensure timely credentialing enrollment and minimize revenue disruption.

Audit and Quality Review

• Perform routine internal audits of credentialing files, provider licensures, board certifications, and credentialing system data.
• Identify potential issues concerning expired licenses, track EIDBI qualifications and provider level change requirements.
• Identify opportunities to improve credentialing processes, tracking methods, documentation practices, and workflow efficiency while maintaining compliance with organizational, payer, and regulatory requirements.

Communication and Collaboration

• Coordinate with providers, leadership, payers, and internal departments to resolve credentialing issues efficiently.
• Build and maintain positive working relationships with providers, payers, and internal stakeholders to facilitate timely credentialing, enrollment, and compliance activities.
• Communicate proactively regarding credentialing status, outstanding requirements, upcoming renewals, and potential compliance concerns.

Renewal Tracking

• Monitor and track credentialing documentation expiration dates.
• Communicate with providers regarding upcoming renewal requirements with insurance payer credentialing, professional licensing and certification renewals.

Performance Metrics

• Timely submission of initial credentialing and re-credentialing applications.
• Zero lapse rate in provider licensures, board certifications, and payer enrollment.
• Minimal provider DHS enrollment denials and re-submission.
• Accuracy rate of credentialing files (audit-ready standard).
• Minimization of revenue disruption due to credentialing delays.
• Proactive tracking and reporting of provider DHS and insurance payers credentialing status.

Required Skills

• Relationship Management: Ability to build collaborative working relationships with providers, payers, and internal stakeholders while maintaining a high level of professionalism and customer service.
• Time Management and Prioritization: Ability to manage multiple deadlines, competing priorities, and credentialing timelines in a fast-paced environment.
• Attention to Detail: Ability to accurately review and verify complex medical and regulatory documentation.
• EIDBI Qualifications & Standards: Knowledge of and/or experience with EIDBI services, DHS requirements, and regulatory guidelines.
• Strong Organizational Skills: Effectively manage multiple credentialing provider enrollments and professional licensing renewal timelines.
• Excellent Communication Skills: Communicate clearly with providers, payers, and internal stakeholders.
• Confidentiality: Ability to maintain confidentiality and appropriately handle sensitive provider and organizational information.
• Data Analytics: Identify discrepancies, inconsistencies, and/or missing document information with provider data files to mitigate credentialing application errors.
• Critical Thinking: Ability to communicate and resolve complex credentialing issues effectively and in a timely manner.
• Knowledge of Healthcare Regulations & Standards: Understanding of federal, Minnesota DHS licensing requirements, policies, and accreditation standards.
• Technology Proficiency: Proficiency with Microsoft Office applications, particularly Excel, and the ability to learn and effectively utilize credentialing systems, payer portals, and related technology platforms.

Required Education and Experience

• High School diploma or equivalent required.
• 35 years of experience in end-to-end provider credentialing, DHS enrollment, or a similar healthcare administrative role.

Preferred Qualifications

• Associate or Bachelor's degree in Healthcare, Business Administration, or related field.
• Certified Provider Credentialing Specialist (CPCS) certification is strongly valued.
• Knowledge of Early Intensive Developmental and Behavioral Intervention (EIDBI) services and qualifications.
• Experience with credentialing systems (MNits, MCC, CAQH, etc.) with healthcare organizations (3+ years preferred).
• Minnesota Health Care Program (MHCP) service experience.

Physical Requirements

• Prolonged periods sitting at a desk and working on a computer.

Benefits

• Generous PTO
• Paid holidays
• Medical, dental, and vision with employer contribution
• 401(k) with employer match
• Employer-paid life and disability insurance

About MAC

Founded in 1996 by parents seeking the highest quality treatment for children and adolescents with autism spectrum disorder (ASD), Minnesota Autism Center (MAC) provides therapeutic

MAC Midwest is a nonprofit provider of coordinated neurodevelopmental care and a recognized leader in the field, with 30 years of experience serving individuals with autism and related conditions and their families across Minnesota. Through a comprehensive, transdisciplinary model, we provide diagnostic assessments, compassionate ABA therapy, mental health services, speech and occupational therapy, and family training.

MAC is an Equal Opportunity Employer and does not discriminate in terms or conditions of employment on the basis of sex (including pregnancy, childbirth, and related medical conditions), race, traits associated with race (including hair texture and style), color, national origin, religion, creed, age once having reached the age of majority, sexual orientation, gender identity, gender expression, military status, veteran status, disability, marital status, familial status, genetic information, status with respect to public assistance, or any other characteristics that are protected by federal, state, or local laws.

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.