Credentialing Specialist

NeighborHealth Center•Raleigh, NC

11d•Hybrid

About The Position

The Credentialing Specialist credentials and recredentials NeighborHealth Center providers and supports their enrollment with participating client health plans. The role processes credentialing and malpractice insurance applications, performs primary source verification, and maintains the CAQH credentialing database in accordance with internal policies and procedures, client health plan contracts, HRSA guidelines, and applicable state and federal requirements. The position gathers, verifies, and evaluates confidential provider credentials; monitors expiring licenses, certifications, and other documents; maintains provider records; and ensures accurate database information and timely completion and handoff of provider files. It responds to inquiries, follows up to resolve discrepancies, monitors compliance, coordinates with HR, and keeps HR and the Billing Manager informed of potential credentialing or enrollment issues. This is a full-time, non-exempt position. Work is scheduled Monday through Friday during routine business hours, with onsite presence required at least once a week. Remote work requires a private home workspace and a secure, password-protected internet connection.

Requirements

Minimum of 3 years of experience in provider credentialing in a managed care setting.
Experience with medical and professional credentialing processes, policies and procedures, and delegated credentialing requirements.
Computer literacy, including internet use and the Windows environment, with Outlook, Word, and Excel.
Ability to develop inclusive and equitable working relationships with coworkers and community members.
Ability to advocate for individuals of all ethnicities, genders, ages, and backgrounds.
Clear and concise verbal and written communication skills.
Ability to meet tight deadlines, respond to changing demands, and provide efficient follow-up.
Ability to handle sensitive and confidential information with discretion and trust.
Ability to work Monday through Friday during routine business hours, with scheduled onsite presence at least once a week.
For remote work, ability to use a private home workspace where screens and conversations cannot be seen or overheard, with a secure, password-protected home internet connection that is not shared or public Wi-Fi.
Fluency in reading, writing, speaking, and comprehending English as needed for essential job functions, including communication, documentation, and safety-related instructions.
With or without reasonable accommodation, ability to sit or stand, often for prolonged periods.

Nice To Haves

Associate degree or an equivalent combination of education and/or experience.

Responsibilities

Initiate and support provider applications by sending, receiving, and analyzing provider documents and importing data to determine completeness before credential verification.
Gather, verify, and evaluate confidential and sensitive healthcare provider credentials in accordance with departmental guidelines and accreditation standards.
Perform initial credentialing and recredentialing, ensuring credentials are current and provider files are handed off or reviewed and approved in a timely manner.
Respond promptly to inquiries from providers, client health plans, and internal stakeholders.
Monitor expiring licenses, board credentials, professional certifications, and other documents, and follow up with providers within prescribed timeframes.
Maintain provider paper and electronic files and use CAQH to submit provider data as required.
Enter data accurately to preserve the integrity of credentialing information in applicable databases.
Collaborate with HR to facilitate a smooth handoff during credentialing.
Follow up with providers and internal and external entities to resolve credentialing discrepancies.
Monitor compliance and immediately alert HR to undisclosed negative findings.
Help review, process, and distribute incoming correspondence, including interdepartmental mail, faxes, and email.
Keep HR and the Billing Manager informed of potential credentialing or enrollment issues.
Perform other duties as assigned.