Credentialing Specialist

Credentialing Specialist

AmeriPharma is a rapidly growing healthcare company where you will have the opportunity to contribute to our joint success on a daily basis. We value new ideas, creativity, and productivity. We like people who are passionate about their roles and people who like to grow and change as the company evolves.

AmeriPharma's Benefits

• Full benefits package including medical, dental, vision, life that fits your lifestyle and goals
• Great pay and general compensation structures
• Employee assistance program to assist with mental health, legal questions, financial counseling etc.
• Comprehensive PTO and sick leave options
• 401k program
• Plenty of opportunities for growth and advancement
• Company sponsored outings and team-building events
• Casual Fridays

Job Summary

The Credentialing Specialist is responsible for leading and overseeing the full credentialing lifecycle for AmeriPharma facilities from state licensing to payer enrollment. This includes initiating and managing provider licensing and payer enrollment applications, as well as maintaining active credentials across all applicable states and payer networks. The ideal candidate will possess strong organizational skills, attention to detail, and familiarity with regulatory and payer specific requirements. This role is essential for maintaining uninterrupted payer participation and ensuring compliance with healthcare regulations and payer standards.

Schedule Details

• Location: On-Site, Laguna Hills, CA
• Hours: Monday-Friday, 8:00 AM - 4:30 PM

Duties and Responsibilities

• Complete and submit initial and recredentialing applications for providers across all payers and facilities, ensuring accuracy and timely delivery.
• Lead payer enrollment and re-enrollment processes in close coordination with the billing and operations teams.
• Track, maintain, and organize all credentialing documentation, including but not limited to State(s) licenses, DEA, NPI Registry, and board certifications.
• Ensure all provider data in the credentialing database, including demographics, effective dates, approvals, and denials.
• Monitor expiration dates for credentials and contracts and proactively manage revalidation and renewals.
• Participate in credentialing audits conducted by health plans, ensuring all documentation is accurate, complete, and audit-ready.
• Maintain strong working relationships with payer representatives and facility contacts to ensure timely execution of contracts, amendments, and credentialing audits.
• Ensure full compliance with all regulatory, payer-specific, and credentialing requirements.
• Respond to medical record requests from patients, legal offices, and referring facilities in accordance with HIPAA.
• Coordinate the release of information, ensuring proper authorization is on file.
• Maintain accurate tracking logs and follow-up systems for credentialing records and medical record requests.
• Provide regular status reports to the Director of Regulatory Affairs on licensing and payer credentialing, and contracting progress.
• Develop and maintain repeatable workflows for all credentialing processes, including initial enrollment, recredentialing, revalidation, and demographic updates.
• Perform other duties as assigned to support regulatory and credentialing functions.

Required Qualifications

• Strong verbal and written communication skills.
• Excellent interpersonal, sales, and customer service skills.
• Excellent organizational skills and attention to detail.
• Effective time management skills with a proven ability to meet deadlines in a fast-paced environment.
• Strong analytical and problem-solving skills.
• Strong supervisory and leadership skills.
• Ability to prioritize tasks and, when appropriate, delegate effectively.
• Proficient in Microsoft Office Suite or similar software.

Preferred Qualifications

• 13 years of experience in credentialing within a PBM, health plan, IPA, or medical group
• Certified Provider Credentialing Specialist (CPCS) certification preferred.

Education and Experience Requirements

Bachelor's degree in Healthcare Administration, Business, Finance, or related field; or equivalent combination of education and experience. Strong knowledge of Medicare, Medicaid, CAQH, PECOS, NPPES, and commercial payer systems. Familiarity with HIPAA regulations and medical record handling.

AmeriPharma's Mission Statement

Our goal is to achieve superior clinical and economic outcomes while maintaining the utmost compassion and care for our patients. It is our joint and individual responsibility daily to demonstrate to outpatients, prescribers, colleagues, and others that We Care!

Physical Requirements

The following physical activities described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions and expectations

EEO Statement

The above statements are intended to describe the work being performed by people assigned to this job. They are not intended to be an exhaustive list of all responsibilities, duties and skills required. The duties and responsibilities of this position are subject to change and other duties may be assigned or removed at any time. AmeriPharma values diversity in its workforce and is proud to be an AAP/EEO employer. All qualified applicants will receive consideration for employment without regard to race, sex, color, religion, sexual orientation, gender identity, national origin, age, protected veteran status, or on the basis of disability or any other legally protected class.