Credentialling Specialist

About the Role

We are seeking a detail-oriented Credentialing Specialist with 3+ years of experience to join our team. This role is responsible for managing the end-to-end credentialing and re-credentialing process for providers, ensuring compliance with regulatory, payer, and accreditation standards. The ideal candidate has strong organizational skills, a keen eye for detail, and experience navigating credentialing databases and payer enrollment systems.

Key Responsibilities

Process initial credentialing and re-credentialing applications for physicians, nurse practitioners, and other healthcare providers

Verify provider credentials, including licenses, education, board certifications, malpractice history, and work history through primary source verification (PSV)

Maintain accurate and up-to-date provider files in credentialing databases MD-Staff

Coordinate with payers to complete provider enrollment and ensure timely reimbursement eligibility

Track expiring licenses, certifications, and insurance to ensure continuous compliance

Prepare credentialing files for committee review and present findings as needed

Ensure compliance with NCQA, URAC, CMS, Joint Commission, and state/federal regulations

Respond to internal and external inquiries regarding provider credentialing status

Maintain confidentiality of sensitive provider information in accordance with HIPAA

Identify and resolve discrepancies in credentialing files in a timely manner

Support audits and provide documentation as requested

Qualifications

3+ years of credentialing experience in a healthcare, managed care, or hospital setting

Bachelor's degree preferred

Strong knowledge of credentialing standards (NCQA, URAC, CMS) and primary source verification processes

Experience with credentialing software/databases (CAQH, MD-Staff)

Familiarity with payer enrollment processes (Medicare, Medicaid, commercial insurers)

Excellent attention to detail and organizational skills

Strong written and verbal communication skills

Ability to manage multiple priorities and meet deadlines in a fast-paced environment

Proficiency in Microsoft Office (Excel, Word, Outlook)

Preferred Skills

Experience with delegated credentialing audits

Knowledge of state-specific licensing requirements

Prior experience supporting medical staff committees or credentialing committees