Credentialing Specialist

Credentialing Specialist

The Credentialing Specialist is responsible for supporting the organization's provider credentialing, recredentialing, and payer enrollment processes in accordance with regulatory, contractual, and accreditation standards. This role ensures the accuracy, completeness, and timeliness of credentialing activities for physicians, allied health professionals, and facilities across all lines of business, including Commercial, Medicare, and Medi-Cal.

The Credentialing Specialist works closely with providers, internal departments, health plans, and external agencies to maintain credentialing compliance, support network readiness, and ensure timely provider enrollment and participation. This position plays a key role in maintaining accurate credentialing records, supporting delegated credentialing requirements, and facilitating efficient provider onboarding within the clinic and IPA/MSO environment.

Requirements

Minimum & Preferred Qualifications:

Education/Training

Minimum: High School diploma or equivalent required.

Preferred: Bachelor's degree in Healthcare Administration, Business Administration, or related field.

Experience

Minimum: At least two years of credentialing experience in a managed care, IPA, MSO, medical group, or health plan environment.

Preferred: Experience with delegated credentialing environments. Experience working with multiple health plans and provider networks. Experience with credentialing software systems and payer enrollment platforms.

Any combination of educational and work experience that would be equivalent to the stated minimum requirements would qualify for consideration of this position.

Certification(s)

None

Skills, Knowledge & Abilities

· Knowledge of credentialing standards and regulatory requirements including NCQA, CMS, DMHC, DHCS, Medicare Advantage, and Medi-Cal.

· Knowledge of primary source verification processes and credentialing file components.

· Knowledge of delegated credentialing models and health plan requirements.

· Knowledge of payer enrollment processes including PECOS, PAVE, NPPES, and CAQH.

· Proficiency with credentialing software platforms such as CAQH, CredentialStream, Modio, or similar systems.

· Strong organizational and time management skills.

· Excellent written and verbal communication skills.

· Strong attention to detail and accuracy.

· Ability to maintain confidentiality and handle sensitive provider information.

· Ability to work independently and collaboratively in a team environment.

· Ability to prioritize tasks and manage multiple credentialing files and deadlines.

· Ability to interpret and apply credentialing policies and regulatory standards.

Physical, Mental & Environmental Requirements:

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. Work is primarily performed in a standard office or hybrid office environment and requires prolonged periods of sitting, frequent use of computers, telephones, and office equipment. The role requires sustained mental concentration, attention to detail, and the ability to review and verify credentialing documentation accurately. Occasional lifting or moving of materials up to approximately 15–20 pounds may be required. This role requires the ability to communicate effectively with providers, staff, and external partners, and to maintain confidentiality of sensitive credentialing information.

Pay Range

$28.85 - $36.05 / hourly