Credentialing Specialist

NeighborHealth Center•Raleigh, NC

2d•Hybrid

About The Position

The Credentialing Specialist is responsible for credentialing and recredentialing NeighborHealth Center providers and ensuring their enrollment with participating client health plans. The role processes credentialing and malpractice insurance applications, conducts primary source verification, and maintains the CAQH credentialing database in accordance with internal policies and procedures, health plan contracts, HRSA guidelines, and applicable state and federal requirements. The position supports provider applications, verifies and evaluates confidential provider credentials, monitors expiring credentials, maintains provider records, responds to inquiries, and collaborates with HR and other internal and external parties to address discrepancies and enrollment issues. It is full-time and non-exempt, with routine weekday business hours and scheduled onsite presence required at least once a week. Remote work requires a private home workspace and a secure, password-protected internet connection.

Requirements

At least 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, Outlook, Word, and Excel.
Ability to cultivate and 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 work under tight deadlines, respond to rapidly changing demands, and provide efficient follow-up.
Ability to handle sensitive and confidential information with discretion and trust.
Availability to work Monday through Friday during routine business hours, with scheduled onsite presence at least once a week.
For remote work, ability to work in a private home workspace where screens and conversations cannot be seen or overheard, using a secure, password-protected home internet connection that is not shared or public Wi-Fi.
Fluent English reading, writing, speaking, and comprehension sufficient for essential job functions, including communication, documentation, and safety-related instructions.
Ability, with or without reasonable accommodation, 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 credentialing verification, including initial credentialing and recredentialing, and ensure current credentials and timely handoff or review and approval of provider files.
Respond promptly to provider, client health plan, and internal inquiries.
Monitor expiring licensure, board and professional certifications, and other expirable documents, coordinating with providers within prescribed timeframes.
Maintain provider paper and electronic files, using CAQH to submit provider data as required for credentialing.
Enter data accurately to preserve the integrity of credentialing information in applicable databases.
Collaborate with HR to facilitate a smooth hand-off during the credentialing process.
Follow up with providers and internal and external entities to resolve credentialing discrepancies.
Monitor compliance and alert HR immediately to undisclosed negative findings.
Share responsibility for reviewing, processing, and distributing 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.