Credentialing Specialist

Credentialing Specialist
Position Summary
The Credentialing Manager is responsible for overseeing all provider credentialing, recredentialing, privileging, and enrollment activities across the organization. This role ensures providers are credentialed accurately and timely with all payers, hospitals, and regulatory entities to support uninterrupted patient care and revenue cycle operations. The Credentialing Specialist will lead process improvement initiatives, maintain compliance with regulatory standards, and partner closely with operations, revenue cycle, recruiting, and clinical leadership teams.Key Responsibilities
Credentialing & Provider Enrollment

• Manage the full lifecycle of provider credentialing, recredentialing, privileging, and payer enrollment processes for physicians and advanced practice providers.
• Ensure timely submission and follow-up of applications with commercial payers, Medicare, Medicaid, hospitals, and ancillary facilities.
• Monitor credentialing expirables including licenses, DEA registrations, board certifications, malpractice insurance, and CME requirements.
• Maintain accurate provider records within credentialing databases and CAQH profiles.
• Oversee provider onboarding timelines to ensure providers are credentialed and enrolled prior to start dates whenever possible.
• Coordinate provider privileging and medical staff applications with hospitals and surgery centers.

Compliance & Quality Assurance

• Ensure compliance with NCQA, CMS, state, and payer credentialing standards.
• Develop and maintain credentialing policies, procedures, and audit readiness documentation.
• Conduct routine audits of provider files and credentialing records.
• Monitor regulatory changes impacting credentialing and provider enrollment.

Leadership & Operations

• Establish and track credentialing KPIs such as enrollment turnaround time, application aging, and provider readiness timelines.
• Collaborate with recruiting and onboarding teams to improve provider start-date readiness.
• Partner with revenue cycle leadership to minimize delays in billing due to credentialing issues.
• Identify workflow inefficiencies and implement process improvements and automation opportunities.

Communication & Cross-Functional Partnership

• Serve as the primary escalation point for credentialing-related issues.
• Communicate credentialing status updates regularly to operational and executive leadership.
• Support provider acquisition, expansion, and de novo clinic initiatives through credentialing coordination.
• Build strong working relationships with payers, hospital systems, and third-party credentialing partners.

Qualifications
Required

• Bachelor’s degree or equivalent experience preferred.
• 2-3+ years of provider credentialing experience in healthcare.
• Strong understanding of payer enrollment, privileging, and credentialing regulations.
• Experience with Medicare, Medicaid, and commercial payer enrollment processes.
• Proficiency with credentialing software platforms, CAQH, PECOS, and provider databases.
• Strong organizational skills with exceptional attention to detail.
• Ability to manage multiple priorities and deadlines in a fast-paced environment.

Preferred

• CPCS (Certified Provider Credentialing Specialist) or CPMSM certification.
• Experience in multi-site physician practice management or healthcare roll-up environments.
• Familiarity with pain management, surgical, or specialty practice operations.
• Experience leading credentialing process optimization initiatives.

Key Competencies

• Operational leadership
• Process improvement mindset
• Attention to detail
• Problem-solving and critical thinking
• Strong communication and stakeholder management
• Compliance orientation
• Ability to work cross-functionally

Success Metrics

• Reduction in credentialing turnaround times
• Percentage of providers credentialed before start date
• Clean application submission rate
• Reduction in payer enrollment delays impacting billing
• Compliance audit readiness and accuracy
• Provider onboarding satisfaction

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