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
• Bachelors 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