Credentialing Specialist

Appalachian Regional Healthcare, Inc.•Lexington, KY

About The Position

The Credentialing Specialist performs the organization’s credentialing, re-credentialing, and privileging processes. The position reports directly to the System Director of Medical Affairs and Provider Enrollment. The role supports accurate, compliant credentialing operations, maintains secure provider records, and coordinates completed files through established Medical Staff review and approval processes.

Requirements

High school diploma required.
Knowledge and understanding of the provider credentialing process.
Ability to organize and prioritize work effectively and manage multiple priorities simultaneously.
Excellent verbal and written communication skills, including the ability to prepare professional correspondence, memoranda, and emails.
Strong attention to detail and accuracy.
Ability to research, analyze, and interpret data.
Ability to work independently with minimal supervision.
Ability to establish and maintain effective working relationships with providers, management, staff, and external contacts.
Proficiency in Microsoft Office applications, including Word and Excel.
Ability to use internet-based resources and credentialing databases effectively.

Nice To Haves

Associate degree preferred.
Two years of relevant credentialing experience preferred.
Certified Provider Credentialing Specialist (CPCS) certification preferred, but not required.

Responsibilities

Process and maintain provider credentialing and privileging files in accordance with organizational policies, regulatory requirements, and accreditation standards.
Complete routine and assigned credentialing activities accurately and in a timely manner.
Process provider pre-applications and review submitted documentation for completeness.
Prepare credentialing application packets and distribute them to providers for completion.
Review and screen initial appointment and reappointment applications for accuracy, completeness, and compliance with applicable policies, regulations, and guidelines.
Identify, analyze, and resolve discrepancies, gaps in employment or training history, unusual findings, and other issues that may affect credentialing.
Communicate credentialing concerns and potential issues to Medical Affairs to support informed decision-making under Medical Staff Bylaws and credentialing policies.
Participate in developing, implementing, and continuously improving system-wide credentialing processes and procedures.
Communicate with providers, provider representatives, Medical Affairs personnel, Medical Staff leadership, and administrative staff regarding credentialing and privileging matters.
Respond promptly to requests and inquiries related to credentialing and privileging activities.
Establish and maintain accurate provider records in credentialing databases and related systems.
Maintain current knowledge of healthcare regulations, accreditation standards, and credentialing best practices through continuing education, seminars, workshops, and professional affiliations.
Perform primary source verification for all required credentialing elements.
Coordinate with the Medical Staff Office to submit completed credentialing files for review, recommendation, and approval through established Medical Staff processes.
Maintain strict confidentiality of provider information and credentialing records.
Ensure the accuracy, integrity, and security of credentialing documentation and electronic records.
Perform miscellaneous duties and special projects as assigned.