Clinical Credentialing and Compliance Specialist

High Point University•High Point, NC

About The Position

High Point University is seeking a Clinical Credentialing and Compliance Specialist who is responsible for managing the credentialing, recredentialing, and ongoing compliance activities for licensed clinical providers primarily within dental services and emerging optometry clinical operations, including medical billing and payer requirements associated with dental procedures billed under medical insurance. This role ensures that all providers meet federal, state, accreditation, payer, and organizational requirements prior to appointment and throughout the duration of their service. The Specialist serves as a key liaison between providers, licensing boards, payers, and internal departments to maintain accurate, timely, and compliant credentialing records.

Requirements

Associate’s degree required; bachelor’s degree in healthcare administration, business management, or a related field preferred.
Minimum of 2 years of healthcare credentialing experience with emphasis on dental providers and services, including medical and optometry credentialing as applicable.
CAQH enrollment and maintenance knowledge.
Medicare enrollment and revalidation knowledge required.
Knowledge of NCQA, Joint Commission, CMS, and state licensing requirements.
In-depth knowledge of dental and optometry regulatory requirements, licensure standards, and compliance obligations.
Strong analytical and problem-solving skills.
Excellent communication and interpersonal skills.
Detail-oriented and highly organized.
Proficiency in credentialing software and compliance tools.

Nice To Haves

Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) preferred.
Experience in an academic dental or optometry clinic setting, FQHC, or multi-specialty practice preferred.
Familiarity with Joint Commission, NCQA, HRSA, CMS, and state-specific regulatory requirements.
Professional certifications in healthcare credentialing, compliance, or dental practice management are a plus.

Responsibilities

Credentialing and Enrollment Management Coordinate initial credentialing and recredentialing for dental, and optometry providers, including dentists, optometrists, and other licensed clinical personnel, including medical payer enrollment related to dental services as applicable.
Verify education, training, licensure, board certification, DEA registration, clinical privileges, work history, and professional references in accordance with organizational policy and regulatory standards.
Prepare and maintain credentialing files, ensuring all documentation is complete, accurate, and current.
Track expirations and proactively manage renewals for licenses, certifications, malpractice insurance, and other required credentials.
Prepare credentialing files for review by credentialing committees, clinical leadership, or governing bodies.
Develop and implement efficient enrollment procedures for new dental and optometry providers, optimizing the onboarding process and minimizing time-to-productivity.
Compliance and Regulatory Oversight Ensure credentialing processes comply with applicable regulations and standards, including but not limited to CMS, Joint Commission, NCQA, HRSA, state licensing boards, and payer requirements.
Monitor and ensure compliance with dental and optometry regulatory requirements, including state and federal laws and payer standards.
Assist with audits, site visits, and surveys by accrediting bodies and regulatory agencies; compile and present requested documentation.
Identify compliance gaps or credentialing risks and escalate concerns to leadership as appropriate.
Data Management and Reporting Maintain credentialing data within credentialing management systems, HRIS, or other databases.
Generate reports related to credentialing status, expirations, compliance metrics, and audit readiness.
Ensure confidentiality and security of all credentialing and provider information.
Collaboration and Communication Serve as primary point of contact for providers regarding credentialing, recredentialing, and compliance questions.
Coordinate with Human Resources, Billing, and Clinical Leadership to support provider onboarding and ongoing compliance.
Provide guidance and education to providers related to credentialing and timelines.