Credentialing Specialist

Paradigm • Tampa, FL

14d • $29 - $33 • Hybrid

About The Position

Paradigm is an accountable specialty care management organization focused on improving outcomes for people with complex injuries and diagnoses. The Credentialing Operations Specialist provides administrative and technical expertise for credentialing services and functions. The role supports credentialing and re-credentialing of internal and affiliated community practitioners, maintains credentialing records and files, verifies practitioner credentials, coordinates information for Credentialing/Peer Review Committee meetings, and supports compliance with applicable policies, standards, regulations, and laws.

The position emphasizes a customer-first approach and collaboration with internal and external partners to deliver high-quality service. The specialist is expected to maintain confidentiality, protect information in accordance with company security policies, attend work reliably, and use AI tools and other new technologies in alignment with established processes and guidelines. The job is full-time and hybrid.

Requirements

• Exceptional communication and telephone skills, patience, and understanding.
• High level of self-confidence and persistence, with an assertive approach when dealing with providers.
• Excellent organizational skills and ability to multitask effectively.
• Ability to prioritize a heavy workload and work independently with minimal supervision.
• Proficient computer and internet skills; familiarity with Microsoft Office software required.
• Bachelor’s degree in a health care or technical field preferred.
• Call center experience is a plus.
• Experience working with physicians and/or senior executives preferred.
• Knowledge of medical terminology preferred.
• Ability to develop in-depth knowledge of department and company workflows, including state-specific procedures and negotiating protocols.
• Bilingual ability is a plus.

Nice To Haves

• Bachelor’s degree in a health care or technical field.
• Call center experience.
• Experience working with physicians and/or senior executives.
• Knowledge of medical terminology.
• Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff Coordinator (CMSC) certification through the National Association Medical Staff Services (NAMSS).
• Bilingual ability.

Responsibilities

• Complete credentialing and re-credentialing applications for internal and affiliated community practitioners.
• Process requests and investigate, verify, track, and follow up on primary responses from credentialing sources.
• Identify, investigate, report, track, and follow up on potentially adverse information received from credentialing sources.
• Maintain knowledge of company policies and procedures, accreditation standards, and applicable state and federal regulations, guidelines, procedures, and laws.
• Populate, update, and maintain credentialing software and filing systems.
• Assist with Requests for Proposals and requested reports in collaboration with a supervisor or other Credentialing Services staff.
• Maintain practitioner files annually.
• Ensure affiliated community practitioners’ medical licenses, DEA certificates, and malpractice certificates remain current.
• Coordinate with designated QAIR Peer Review and Member Services personnel before Credentialing/Peer Review meetings and incorporate Peer Review information into credentialing and re-credentialing files.
• Collect site visit information from Provider Relations for practitioner files in preparation for Credentialing/Peer Review Committee approval meetings.
• Coordinate with Risk Management on risk management, substance abuse, and malpractice issues; review files for red flags.
• Prepare practitioner profiles and complete permanent files for review and approval at Credentialing/Peer Review Committee meetings.
• Participate in professional or other organizations addressing credentialing, compliance, or risk management activities.
• Maintain strict confidentiality of records, data, and occurrences.
• Maintain reliable and predictable attendance during scheduled work hours.
• Use AI tools to support day-to-day tasks, improve efficiency, and enhance output quality; adopt new technologies as trained and apply them according to established processes and guidelines.
• Develop a broad understanding of Paradigm’s organization, products, operations, and customers; collaborate to meet customer needs and take accountability for service quality.
• Comply with Paradigm Information Security requirements and policies, safeguard company-related passwords, and report information security incidents according to policy SEC 10-12.

Benefits

• PPO, HDHP, and HMO health insurance options through Cigna and Kaiser (Kaiser for California employees only).
• 401(k) matching contributions.
• Employer-paid life and disability insurance.
• Flexible spending and commuter accounts.
• Employer-matched HSA contributions.
• Paid time off and personal holiday programs.
• One paid volunteer day per calendar year for full- and part-time employees.
• Learning and development support, including the Learning Excellence at Paradigm (LEAP) program.
• Competitive salaries.

What This Job Offers

• Job Type: Full-time
• Education Level: No Education Listed