CREDENTIALING SPECIALIST

MISSION

The mission of Ravenswood Family Health Network (RFHN) is to improve the health of the community by providing culturally sensitive, integrated primary and preventative health care to all, regardless of ability to pay or immigration status, and collaborating with community partners to address the social determinants of health.

POSITION Summary

Under the general direction of the Compliance Project Manager, the Credentialing Specialist coordinates Ravenswood Family Health Network’s (RFHN’s) credentialing and privileging program and operational relationship between RFHN’s clinical providers and external health plan partners. This role ensures providers are accurately represented, appropriately enrolled, and continuously active across contracted health plans and programs. Acting as a central liaison, the Specialist coordinates provider participation, data integrity, and communication across internal departments and external partners to support access, compliance, and continuity of services for Ravenswood Family Health Network.

Duties and Responsibilities

To be performed in accordance with RFHN Policies and Procedures

1. Processes credentialing and re-credentialing applications and ensures RFHN database on practitioners’ education, training, licensing, experience and other information is properly maintained, managed, and that periodic reports are provided to the medical staff leadership, the Compliance Team, and the Board of Directors, as necessary.
2. Supports the development and maintains policies and procedures for medical staff credentialing and privileging.
3. Serve as a primary point of contact for health plan partners regarding provider participation, roster accuracy, network status, and data validation.
4. Manage provider participation throughout its lifecycle, including onboarding, status changes, and terminations, ensuring timely communication and documentation.
5. Maintain authoritative provider records in ASM MD-Staff and ensure consistency across internal systems, health plan rosters, and operational databases.
6. Coordinate provider enrollment, updates, and revalidation activities required by health plan partners in collaboration with Billing and other internal teams.

General Agency Duties

1. Respond to and resolve data discrepancies, follow-up requests, and participation-related inquiries from external partners.
2. Collaborate with HR, Staff Development, Compliance, Billing, and clinical leadership to collect, verify, and reconcile provider information.
3. Monitor participation-related risks (such as expiring licenses, sanctions, or incomplete documentation) and proactively coordinate resolution to prevent disruption in provider participation.
4. Prepare and maintain provider rosters, participation summaries, and data reports for external partners and internal stakeholders.
5. Support reviews, audits, and outreach related to provider participation and network management.
6. Administrator of RFHN’s medical staff services software (MD-Staff).
7. Performs primary source verification of credentials, i.e. education, licenses, certifications, and references.
8. Performs other duties as assigned and requested.