Credentialing Specialist

Island Health Careers•Anacortes, WA

2d•$25 - $37•Onsite

About The Position

At Island Health, people are at the center of everything we do. As a part of the Patient Accounts Team, you’ll play a vital role in supporting our mission to care for those who care for others. You’ll help create a positive and seamless experience for every team member — ensuring they feel valued, supported, and heard. In the Credentialing Specialist role, you will play a key role for overseeing and coordinating the credentialing and privileging process for new and established practitioners and preparing financial and risk analysis to support payer contract management and negotiations. The role ensures providers meet payer/health plan requirements through primary source verification and accurate provider database management, while also designing models and performing analyses to evaluate historical and future contract performance, monitor payment compliance, and support resolution of payment discrepancies and denials tied to contract terms.

Requirements

Strong analytical, investigative, organizational, and critical thinking skills; ability to synthesize information and concisely communicate findings and recommendations.
Detail-oriented; strong problem-solving, conflict resolution, time management, and task prioritization skills; ability to meet deadlines and work independently with minimal supervision.
Broad understanding of computer system concepts and database relationships; ability to create reports from data across systems for senior management.
Proficiency in Microsoft Excel and Microsoft Office Suite (Access, Word, Excel, Project, PowerPoint, Outlook).
Working knowledge of data management software applications; experience with credentialing database management software and contract management software preferred.
Excellent written/verbal communication, interpersonal, negotiation, and presentation skills; ability to educate diverse audiences and explain analytic logic to stakeholders.
High school diploma or equivalent required.
At least two (2) years of administrative experience in a hospital or healthcare setting.
Minimum three (3) years of data or financial analytical experience.
Proven experience working directly with healthcare personnel, including physicians and credentialing representatives.

Nice To Haves

Bachelor’s degree in business administration, accounting, statistics, finance, or closely related field preferred (or equivalent combination of education and experience)
Additional training/education in practitioner credentialing preferred.
Certification from the National Association of Medical Staff Services preferred.
Credentialing experience in a hospital setting preferred.
Experience working with cross-functional departments to research and resolve issues using innovative solutions preferred.

Responsibilities

Provider Credentialing & Privileging Manage end-to-end provider credentialing and re-credentialing in compliance with federal/state regulations and accreditation standards (e.g., CMS, Joint Commission, NCQA, HIPAA).
Perform primary source verification, maintain complete and accurate credentialing files, and manage provider data within credentialing systems.
Coordinate with providers, medical staff, contracting, and administrative teams to obtain required documentation and resolve application issues.
Monitor application status, communicate deficiencies, prepare credentialing correspondence, and ensure timely approvals and renewals.
Conduct sanctions monitoring and National Practitioner Data Bank queries; initiate corrective actions as required.
Safeguard confidentiality of credentialing and privileged information and provide responsive customer service to internal and external stakeholders.
Payer Contract Management & Financial Analytics Perform financial, reimbursement, and risk analyses to support payer contract negotiations and ongoing contract management.
Build and maintain financial models to evaluate historical performance, forecast future reimbursement, and assess contract terms.
Prepare routine and ad-hoc reports for leadership to support strategic and operational decision-making.
Maintain contract management systems; monitor payment compliance and identify underpayments, variances, and contract discrepancies.
Review contract language to ensure correct application of rates and provisions and provide guidance on complex reimbursement scenarios.
Support managed care initiatives, including forecasting reimbursement impacts during negotiations and participating in collaborative managed care committees.
Educate leaders and physicians on reimbursement methodologies and payment structures as needed.
Client Billing System Maintain the client billing system for non-patient accounts and ensure accuracy of related data and reporting.