Credentialing Specialist

The Credentialing Specialist is responsible for coordinating and supporting all aspects of provider credentialing, recredentialing, and delegated credentialing oversight. This role ensures provider records are accurate, complete, and compliant with organizational policies and regulatory requirements, including NCQA, CMS, and URAC standards.

The Credentialing Specialist serves as a key liaison between providers, provider offices, internal stakeholders, and credentialing committees to ensure timely and efficient processing of provider credentials.

Essential Duties & Responsibilities

• Coordinate initial credentialing and recredentialing activities for providers and facilities.
• Perform primary source verification of provider education, training, licensure, certifications, malpractice coverage, sanctions, and other required documentation.
• Maintain provider credentialing files and ensure all records are current and audit-ready.
• Manage credentialing workflows and monitor deadlines to ensure timely completion.
• Oversee delegated credentialing activities and conduct reviews to ensure compliance with regulatory requirements.
• Prepare credentialing packets and supporting documentation for Credentialing Committee review.
• Maintain accurate provider data within credentialing databases and systems.
• Generate credentialing reports and track key performance metrics.
• Communicate with providers, provider offices, and internal departments regarding credentialing requirements and status updates.
• Support audits, surveys, accreditation reviews, and compliance initiatives.
• Ensure adherence to NCQA, CMS, URAC, and organizational credentialing standards.
• Participate in process improvement initiatives to enhance credentialing operations.

Required Qualifications

• High School Diploma or GED required.
• Minimum of 3 years of provider credentialing experience in a managed care environment.
• Minimum of 1 year of experience using credentialing software, preferably Verifiable or a Salesforce-based platform.
• Experience performing primary source verification.
• Strong understanding of credentialing and recredentialing processes.
• Excellent organizational skills and attention to detail.
• Strong verbal and written communication skills.
• Proficiency with Microsoft Office applications, including Excel, Word, and Outlook.
• Ability to effectively manage multiple priorities and deadlines.

Preferred Qualifications

• Bachelor's degree in Healthcare Administration, Business Administration, or related field.
• Experience with Verifiable credentialing software.
• Knowledge of NCQA, CMS, and URAC accreditation standards.
• Experience supporting delegated credentialing programs.
• Managed care or health plan experience preferred.

Knowledge, Skills & Abilities

• Strong analytical and problem-solving skills.
• Ability to maintain confidential information and comply with HIPAA requirements.
• Excellent customer service and relationship-building skills.
• Ability to work independently and collaboratively within a team environment.
• Strong time management and prioritization skills.
• Commitment to accuracy, compliance, and continuous improvement.