Credentialing Specialist

JOB DESCRIPTION


Title: Credentialing Specialist


FLSA Category: Exempt


Reports To: Chief Human Resources Officer


Date Issued: September 2021


Revised: January 2023, September 2025

Greater Baden Medical Services (GBMS) is a Federally Qualified Health Center (FQHC) dedicated to providing high-quality healthcare across Southern Maryland. With 9 clinical sites across Prince George's, Charles, and St. Mary's counties, we serve over 18,000 patients each year. We provide fully integrated care that includes primary care, pediatrics, women's health, Title X family planning, dental care, behavioral health, WIC, pharmacy services, and the Ryan White HIV/AIDS program. Our patient population is primarily made up of Medicaid and uninsured individuals. We are deeply proud to deliver these vital services to everyone in our community, regardless of their ability to pay, making Greater Baden an incredibly rewarding place to grow your career while making a tangible, life-changing impact every day.

Job Summary:


Responsible for all aspects of the credentialing, re-credentialing and privileging processes for all medical providers and clinical staff who provide patient care. Responsible for ensuring providers are credentialed, appointed, and privileged with health plans, and patient care facilities. Maintain up-to-date data for each provider in credentialing databases and online systems; ensure timely renewal of licenses and certifications.


Essential Functions:


1. Maintains credentialing files in adherence to HRSA guidelines as it pertains to the credentialing and privileging clinical staff guidelines.


2. Maintains communications with insurance vendor to ensure providers are up to date.


3. Provides timely information to the agent (internal/external) who is charged with monitoring the insurance portals.


4. Completes provider credentialing and re-credentialing applications; monitors applications and follows-up as needed.


5. Reviews and ensures documents submitted are current and correct.


6. Processes applications for appointment and reappointment of privileges within time sensitive deadline.


7. Maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers.


8. Tracks license, DEA and professional liability expirations for appointed providers.


9. Compiles and Ensures that accurate licenses, DEA and professional liability documents are secured and maintained in all providers' files.


10. Compiles and Ensures current CPR and First Aid certificates are maintained in providers' files


11. Works in tandem with the Director of Clinical Education and Support regarding providers re-training in CPR and First Aid. Provides copies of updated certificates to the Director of Clinical Education and Support.


12. Maintains corporate provider contract files.


13. Maintains knowledge of current health plan and agency requirements for credentialing providers.


14. Sets up and maintains provider information in online credentialing databases (CCNV) and system.


15. Tracks license and certification expirations for all providers to ensure timely renewals.


16. Routinely communicates with agent on the status of filings with insurance companies.


17. Ensures practice addresses are current with health plans, agencies and other entities.


18. Audits health plan directories for current and accurate provider information.


19. Assist with the new hire process for LIP's and OLIP's


20. Provide assistance with provider chart review.


21. By maintaining providers' credentialing files, ensures that a healthcare facility is operating within state and federal regulations.


Nonessential Functions:

1. Assist in resolving audit issues assigned by the Chief Medical Officer and Chief Human Resources Officer.

1. Performs other administrative duties as assigned by the Chief Executive Officer.

Supervisory Responsibility


None


Managerial Responsibilities


None


Minimum Qualifications:

1. Associates or Bachelor's Degree in Business Administration, Healthcare

1. Or equivalent certification of competency and three (3) to five (5) years of work experience in medical credentialing

1. At least two (2) years of experience working in the healthcare industry or similar regulatory environment

1. Experience working with local, state and federal agencies in regards to procuring licensing for healthcare providers including background checks

Preferred Qualifications


1. Certified Provider Credentialing Specialist (CPCS)


Work Environment

• This job operates in a professional office environment. This role routinely uses standard office equipment such as computers, phones, photocopiers, filing cabinets and fax machines.

• This job operates in an outpatient office environment.
• Possible exposure to various environments such as: communicable diseases, toxic substances, medicinal preparations and other conditions common to a hospital and medical office environment.

Physical and Mental Demands

1. Ability to remain in a stationary position 50% of the time.

1. Ability to cope with stress.

1. Constantly operates a computer and other office productivity machinery, such as a calculator, copy machine and computer printer.

1. The person in this position frequently communicates with patients and/or employees. Must be able to summarize and exchange accurate information.

1. Performs a variety of duties, often changing from one task to another.

1. Performs with frequent interruption or distractions.

1. Adjust priorities quickly as circumstances dictate.

1. Ability to interact appropriately with colleagues for different purposes in different context.

1. Expressing or exchanging information to convey detailed spoken instructions accurately, or quickly.

1. Ability to judge distances and spatial relationships to see objects where and as they actually are.

1. Cognitive ability to analyze, count, summarize and synthesize information from multiple sources.

Compliance


This position requires compliance with Greater Baden Medical Services ( Health Center's) compliance standards, including its Standards of Conduct, Compliance Program, and policies and procedures. Such compliance will be an element considered as part of the Director of Risk Management's regular performance evaluation.


Language Skills


Ability to read and interpret written or verbal documents and instructions. Ability to speak effectively to patients, employees and/or stakeholders of the organization.


Travel


Must be able to drive between Greater Baden Medical Services, Inc. locations if required.