Credentialing Specialist

Blue Cross of Idaho•Bozeman, MT

1d•$21 - $30•Hybrid

About The Position

The Credentialing Specialist supports the provider credentialing process by reviewing applications, maintaining accurate credentialing records, communicating with providers, and ensuring credentialing activities meet company, federal, state, and regulatory requirements. This role partners closely with internal departments and external stakeholders to support timely, accurate, and compliant provider onboarding and ongoing credentialing operations, including the setup and maintenance of Credentials Committee processes, credentialing policies, and end-to-end workflows and procedures.

Requirements

2 years of experience in a health care industry setting, such as billing, credentialing, provider enrollment, or a state medical regulatory agency.
High School or equivalent

Nice To Haves

One year of experience in provider credentialing.
Experience supporting or performing delegation oversight activities.
Proficiency with data reporting tools, queries, and Microsoft Excel to support tracking, analysis, and operational reporting.

Responsibilities

Coordinate and maintain credentialing activities, including reviewing applications and supporting documentation for completeness, accuracy, to ensure compliance with applicable regulations.
Communicate with providers regarding application status, missing or incomplete information, credentialing requirements, and next steps.
Obtain, review, and evaluate practitioner sanctions, complaints, adverse actions, and other credentialing-related data to support compliant decision-making.
Maintain accurate, complete, and confidential credentialing documentation, including sensitive background information, in accordance with company policies and federal, state, and regulatory requirements.
Compile, evaluate, and prepare provider-specific information for Credentials Committee review, and track related follow-up items, including notifications, appeals, hearing processes, and post-committee actions.
Partner with internal departments to support provider contracting, quality-related activities, remedial action plans, reporting requirements, and ongoing process improvements.
Draft and maintain policies, procedures, workflows, and processes to support operational effectiveness, regulatory compliance, and achievement of department metrics and service-level expectations.
Participate in the formation and facilitation of Credentials Committee processes and workflows.
Support delegation oversight activities, including delegation setup, onboarding of new delegated partners, oversight of delegated credentialing activities, and ongoing monitoring to ensure delegated entities remain compliant with applicable regulations, company requirements, and delegation agreements.
Participate in or conduct credentialing site visits, report adverse credentialing actions to appropriate agencies, and prepare documentation or reports for audits requested by regulatory or accrediting bodies, as applicable.
Build and maintain productive, cooperative working relationships with providers, peers, management, and internal and external stakeholders.
Perform other duties and responsibilities as assigned.