Credentialing Specialist

Rocky Boy Health Center•Box Elder, MT

About The Position

The Credentialing Specialist is responsible for coordinating provider credentialing, privileging, and recredentialing activities to ensure compliance with Rocky Boy Health Center Medical Staff Bylaws, accreditation standards, payer requirements, and applicable federal, state, and tribal regulations. The position conducts comprehensive employee and contractor background investigations, maintains credentialing records and databases, monitors licensure and certification requirements, and supports organizational regulatory compliance. The Credentialing Specialist also assists the Revenue Cycle Manager with provider enrollment and revalidation activities to facilitate timely provider onboarding and billing readiness.

Requirements

Associate's degree in Healthcare Administration, Business Administration, Health Information Management, Human Resources, or a related field; or an equivalent combination of education and experience.
Two (2) years of experience in healthcare credentialing, medical staff services, regulatory compliance, human resources, provider enrollment support, or a related administrative healthcare role.
Strong organizational skills with the ability to manage multiple priorities and meet deadlines.
Proficiency with Microsoft Office and electronic database systems.
Ability to maintain strict confidentiality and exercise sound judgment when handling sensitive information.
Excellent written and verbal communication skills.

Nice To Haves

Bachelor's degree in Healthcare Administration, Business Administration, Health Information Management, Public Administration, or a related field.
Experience with provider credentialing and privileging in an ambulatory healthcare organization, tribal health program, or hospital.
Experience supporting provider enrollment with Medicare, Medicaid, commercial insurance plans, and other third-party payers.
Experience using credentialing and enrollment systems such as CAQH, PECOS, NPPES, or similar platforms.
Familiarity with AAAHC accreditation standards, Indian Health Service operations, and Tribal Self-Governance programs.
Certification such as Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM), or the ability to obtain certification within two years of hire.
Knowledge of federal exclusion databases, provider licensing requirements, and healthcare regulatory compliance.

Responsibilities

Coordinates the initial appointment, reappointment, recredentialing, and privileging processes for physicians, advanced practice providers, dentists, pharmacists, and other licensed independent practitioners.
Performs primary source verification of education, licensure, certifications, training, work history, malpractice coverage, and other credentialing requirements.
Processes credentialing applications in accordance with Medical Staff Bylaws, organizational policies, and accreditation standards.
Queries the National Practitioner Data Bank (NPDB), Office of Inspector General (OIG), System for Award Management (SAM), and other required exclusion or sanction databases.
Maintains confidential credentialing files and electronic credentialing databases.
Monitors provider licenses, certifications, DEA registrations, and other required credentials to ensure timely renewal and continued compliance.
Assists with preparation for accreditation surveys and regulatory reviews.
Assists the Revenue Cycle Manager with provider enrollment, revalidation, and maintenance for Medicare, Medicaid, commercial insurance plans, and other third-party payers.
Maintains enrollment records and assists with payer requests for additional documentation.
Monitors enrollment and revalidation deadlines and communicates upcoming requirements to appropriate staff.
Assists with maintaining provider information in CAQH, PECOS, NPPES, and other enrollment systems as applicable.
Coordinates and conducts comprehensive background investigations for employees, contractors, volunteers, students, and other individuals requiring organizational clearance.
Verifies criminal history, education, employment history, professional references, licensure, certifications, identity, driving records, and other required screening elements.
Maintains knowledge of applicable accreditation standards, credentialing requirements, and regulatory changes affecting provider credentialing and employment screening.
Assists with policy development and updates related to credentialing and regulatory compliance.
Prepares reports and maintains documentation required for audits, accreditation surveys, and regulatory inspections.
Collaborates with Human Resources, Medical Staff, Revenue Cycle, Compliance, and other departments to support organizational objectives.
Performs other duties as assigned.