Credentialing Specialist

Paradigm•Tampa, FL

2d•Hybrid

About The Position

The Credentialing Operations Specialist provides administrative and technical expertise for credentialing services and functions, including credentialing and re-credentialing internal and affiliated community practitioners. The role supports an exceptional customer experience through high-quality service, effective collaboration, and a customer-first approach for injured workers, payors, clients, providers, stakeholders, and internal teams. The position is full-time and hybrid. The specialist processes credentialing applications and verifications, maintains practitioner records and credentialing systems, monitors licenses and certificates, prepares materials for Credentialing/Peer Review Committee meetings, and coordinates with internal teams on peer review, site visits, and risk management matters. The role requires confidentiality, reliable attendance, compliance with information security policies, and adoption of approved AI tools and other technologies to improve efficiency and output quality.

Requirements

Exceptional communication and telephone skills.
Patience and understanding.
High 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.
Ability to develop in-depth knowledge of department and company workflows, including individual state procedures and negotiating protocols.

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 from the National Association Medical Staff Services (NAMSS).
Bilingual ability.

Responsibilities

Complete credentialing and re-credentialing applications for internal and affiliated community practitioners.
Process requests, investigations, verifications, tracking, and follow-up of primary responses from various sources.
Identify, investigate, report, track, and follow up on potentially adverse information received from credentialing sources.
Maintain appropriate 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 medical licenses, DEA certificates, and malpractice certificates for affiliated community practitioners remain current.
Coordinate with designated QAIR Peer Review and Member Services personnel before each Credentialing/Peer Review meeting 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.
Work with Risk Management to identify and coordinate risk management, substance abuse, and malpractice issues.
Review files for red-flag issues.
Prepare practitioner profiles and complete permanent files for review and approval at each Credentialing/Peer Review Committee meeting.
Participate in professional or other organizations addressing credentialing, compliance, and/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 in alignment with established processes and guidelines.
Develop a broad and deep understanding, as appropriate, of the organization, products, operations, and customers; collaborate to meet customer needs and take personal accountability for service quality.
Comply with Paradigm Information Security requirements and policies, safeguard passwords, and report information security incidents as required by policy SEC 10-12.