POSITION OVERVIEW

The Credentialing Specialist is responsible for managing the end-to-end credentialing and recredentialing process for healthcare providers within the Revenue Cycle Management (RCM) framework. This role ensures that providers are properly enrolled with insurance payers and meet all regulatory and organizational requirements to bill for services. The Credentialing Specialist acts as a liaison between providers, payers, and regulatory agencies to maintain accurate provider records and support timely reimbursement.

ESSENTIAL FUNCTIONS INCLUDE, BUT ARE NOT LIMITED TO

• Complete initial credentialing and recredentialing applications for providers with commercial and government payers.
• Maintain accurate and up-to-date provider information in credentialing databases, payer portals, and internal systems.
• Maintain up-to-date CAQH profiles for all providers, including regular updates, re-attestations, and coordination with payer for credentialing purposes.
• Monitor and track application statuses, expirations, and renewals of licenses, certifications, and insurance contracts.
• Communicate regularly with providers to collect required documentation and resolve discrepancies.
• Collaborate with billing teams to ensure credentialing status does not delay claims processing or payment.
• Respond to payer requests for additional documentation or clarification during the credentialing process.
• Ensure compliance with federal, state, and payer-specific credentialing guidelines and timelines.
• Audit credentialing records to ensure data integrity and compliance with internal policies.
• Maintain logs and reports on credentialing activities, status updates, and contract effective dates.

MINIMUM REQUIREMENTS / QUALIFICATIONS

• High school diploma or equivalent required; associate or bachelor’s degree in healthcare administration or related field preferred.
• Minimum of 2 years of experience in healthcare credentialing or provider enrollment; experience with commercial and government payers preferred.
• Proficiency in credentialing software, payer portals (e.g., CAQH, PECOS), and Microsoft Office Suite.
• Understanding of credentialing standards, payer requirements, and basic billing processes; knowledge of HIPAA and healthcare compliance regulations.
• Proficiency with Microsoft Office Suite, particularly Excel and Outlook.
• Understanding of claim adjudication, payment posting, and denial management processes.

KEY CHARACTERISTICS

• Team Player: Ability to work co-operatively and collaboratively with all levels of employees, management, and external customers to maximize performance and problem solving
• Integrity & Accountability: Unwavering commitment to doing what is right and upholding ethical standards. Takes ownership of tasks and maintains thorough documentation.
• Highly Organized: Able to manage multiple credentialing timelines, follow-ups, and renewals with precision.
• Detail-Oriented: Ensures completeness and accuracy of all submitted documents and records.
• Persistent & Proactive: Follows up on applications and resolves delays efficiently to avoid credentialing gaps.
• Problem-Solver: Capable of addressing application issues and preventing rejections.
• Confidential & Compliant: Maintains confidentiality and complies with all regulatory and privacy standards.
• Effective Communicator: Excellent communication skills, both verbal and written. Effectively communicates with internal teams and external payers.

PHYSICAL REQUIREMENTS

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential function.

• Specific vision requirements include the ability to see at close range, distance vision, peripheral vision, depth perception, and the ability to adjust focus.
• While performing the duties of this job, the employee is regularly required to talk and hear.
• Possess the ability to fulfill any office activities normally expected in an office setting, to include, but not limited to: remaining seated for periods of time to perform computer-based work, participating in filing activity, lifting and carrying office supplies (paper reams, mail, etc.).
• Frequently required to stand, walk, sit, use hands to feel, and reach with hand and arms
• Occasionally lift and/or move up to 20-25 pounds.
• Fine hand manipulation (keyboarding).
• Travel may be required to existing or new OCP locations.