Credentialing Specialist

Primary Health Solutions•Hamilton, OH

10d

About The Position

The Credentialing Specialist is responsible for coordinating and maintaining all activities related to credentialing, recredentialing, licensure verification, board certification tracking, and provider privileging for providers and licensed clinical staff. This position ensures compliance with Health Resources and Services Administration (HRSA), Centers for Medicare & Medicaid Services (CMS), state licensing boards, accreditation standards, payer requirements, and organizational policies. The role serves as the central point of contact for credentialing activities and maintains accurate provider records throughout the employment lifecycle. This position does not perform payer enrollment, provider billing, or revenue cycle management functions.

Requirements

High school diploma or GED minimum.
Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals.
Ability to write routine reports and correspondence.
Ability to speak effectively before groups of customers or employees of organization.
Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists.
Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.
Ability to gain knowledge of current practice management system, electronic medical record, Microsoft Word, text paging, Internet, and Intranet.
Maintains confidentiality of all personnel, medical, financial, or other sensitive materials and information in printed, electronic, or verbal form, which may jeopardize the privacy of patients and/or employees.
Accesses and uses the minimum necessary patient identifiable information to perform job responsibilities and only for authorized purposes.

Nice To Haves

Associate degree or higher preferred.
Minimum of 2 years or more relevant healthcare credentialing experience is strongly preferred.
Experience working in an FQHC hospital, medical group, or healthcare organization is preferred.
Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management is preferred.

Responsibilities

Coordinates initial credentialing and recredentialing activities for all licensed clinical personnel, including: Physicians, Nurse Practitioners, Physician Assistants, Pharmacists, Behavioral Health Providers, Registered Nurses, Licensed Practical Nurses, Licensed Clinical Social Workers, Counselors and Therapists, Medical Assistants, Dental Assistants, Pharmacy Technicians and other licensed healthcare professionals as assigned.
Conducts primary source verification for licenses, educational credentials, training and residency completion, board certifications, DEA registrations, National Provider Identifier (NPI) information, OIG, SAM, NPDB, professional references, and sanctions & exclusions.
Maintains complete and accurate credentialing files in accordance with regulatory requirements.
Monitors expiration dates for professional licenses, certifications, BLS certifications, and other required credentials.
Provides timely notifications to employees and leadership regarding upcoming expirations.
Ensures all licensed personnel maintain active and unrestricted credentials as a condition of employment.
Escalates credentialing deficiencies or lapses to leadership immediately.
Completes credentialing checklists for providers and clinical staff in a timely manner before the board cycle.
Retains detailed and accurate records in a standardized format for all clinical staff.
Maintains knowledge of all HRSA and FTCA credentialing and privileging requirements.
Tracks license and certification expirations for all providers and clinical staff to ensure timely renewals.
Assists providers and other staff as necessary with the completion of applications and credentialing paperwork, including gathering appropriate signatures.
Works collaboratively with HR to ensure necessary documents are collected during orientation and before, if applicable.
Maintains confidentiality of provider and staff information.
Conducts periodic audits of credentialing files.
Assists during external audits, surveys, and accreditation reviews.
Generates reports as needed regarding credentialing status, expiring licenses, recredentialing activities and audit findings.
Maintains credentialing databases and tracking systems.