Credentialling Specialist
Summary
Credentialling Specialist managing end-to-end provider credentialing, ensuring compliance with regulatory standards, and maintaining accurate provider files using MD-Staff.
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