Credentialing Specialist

Behavioral Health Network • Springfield, MA

13d

About The Position

The Credentialing Specialist processes initial and biennial recredentialing applications for individual providers and supports onboarding clinical staff by verifying credentials, identity, education, certifications, and work history. The role monitors electronic credentialing workflows, evaluates information from the CVO, and escalates exceptions and identified concerns to the Clinical Director. It ensures applications are processed by the credentialing committee, monitors required licenses and other credentials, and follows up on pending expirations to support compliance.

The specialist maintains credentialing and insurance eligibility records in CredentialStream, reviews alerts for exclusions and sanctions, prepares payer rosters and oversight reports according to insurer schedules, and enrolls and empanels eligible clinical staff as permitted by insurance contracts.

This position is with BHN, a behavioral health organization serving Western Massachusetts. The stated pay range is $24.00–$27.00 per hour, based on experience.

Requirements

• High school diploma or GED.
• Knowledge of insurance, clinical license levels, educational degrees, CPT coding, and guarantor credentialing standards.
• Familiarity with PECOS, NPI, CAQH, the OIG exclusion list, and Med Advantage.
• Insurance background with coding and billing.

Responsibilities

• Process initial credentialing applications and biennial recredentialing applications for individual providers.
• Assist with onboarding clinical staff by verifying credentials, identity, degrees, certifications, and work history.
• Monitor electronic credentialing workflows.
• Evaluate the quality of information provided by the CVO and escalate exceptions to the Clinical Director for review.
• Ensure each individual credentialing application is processed by the credentialing committee for initial and recredentialed clinical staff.
• Monitor state professional licensure, board certification, DEA, CDS, and other required credentials.
• Review pending expiration dates and follow up with staff to ensure compliance.
• Review CredentialStream alerts for state exclusions and professional licensing sanctions, OIG exclusions, SAM exclusions, and federal sanctions; notify the Clinical Director of identified concerns.
• Maintain the CredentialStream database of credentialed staff, including staff credentials and insurance eligibility.
• Prepare payer rosters and credentialing oversight reports according to the cadence defined by each insurance company.
• Enroll and empanel eligible clinical staff as determined by insurance contracts.

Benefits

• Generous paid time off (PTO).
• 403(b).
• Educational assistance.
• Medical insurance.
• Dental insurance.
• Vision insurance.
• Employee assistance programs.
• Ongoing training, mentorship, career development, and advancement opportunities.

What This Job Offers

• Job Type: Full-time
• Education Level: High school or GED