Purpose – The Senior Credentialing Specialist supports the accurate and timely credentialing and re-credentialing of healthcare providers with insurance networks, clearinghouses, and other credentialing bodies. This role involves ability in handling a team, maintaining compliance, ensuring accurate documentation, and coordinating with insurance networks and other credentialing entities.
Key Responsibilities
Credentialing and Recredentialing Support:
- Preparing, submitting, and tracking provider enrollment applications for insurance networks and credentialing organizations.
- Ensure the accuracy and completeness of provider credentialing documentation, including licenses, certifications, and insurance coverage.
- Monitor and update credentialing timelines, ensuring compliance with deadlines and payer requirements.
Compliance and Documentation:
- Perform primary source verifications as directed, maintaining adherence to regulatory and organizational standards.
- Maintain organized credentialing records and ensure accurate data entry in credentialing software or databases.
- Assist in audits of credentialing files to verify compliance with HIPAA and other regulatory requirements.
Communication and Coordination:
- Liaise with healthcare providers, and external entities to resolve credentialing-related issues.
- Follow up with providers, payers, and clearinghouses to gather required information or clarify discrepancies.
- Communicate updates on credentialing processes and progress to the Senior Credentialing Specialist and management.
Administrative Support:
- Prepare reports and summaries of credentialing activities for review by the Credentialing Manager or team.
- Train new team members on credentialing processes and software.
Key Qualifications:
- College or equivalent required; an Associate’s degree in healthcare administration or a related field is preferred.
- More than 5 years experience in healthcare credentialing
- Comprehensive, end-to-end knowledge of provider and facility enrollment processes, as well as current healthcare regulations.
- Proven experience managing full enrollment and revalidation for Medicare, Medicaid, and commercial insurance payers.
- Skilled in utilizing major payer portals and credentialing systems, including PECOS, CAQH, and various insurance carrier platforms.
- Proficient in specialized credentialing software and the Microsoft Office Suite (Word, Excel, Outlook).
- Ability to manage multiple payer enrollments, follow-ups, application submissions, and provider records independently.
- Excellent verbal and written communication skills, with a track record of collaborating effectively across internal teams and external departments.
- Organized with strong attention to detail and the ability to prioritize tasks in a fast-paced environment.
Shift / Hours:
Monday – Friday in one single shift, 9:00 AM EST – 6:00 PM EST. Note this is +12 or +13 Philippine time, which will be 9:00 PM PHT – 6:00 AM in PHT.