Credentialing Specialist

The Credentialing Specialist is responsible for coordinating and maintaining all aspects of the provider credentialing, recredentialing, enrollment, and privileging processes. This position ensures healthcare providers meet all federal, state, payer, and organizational requirements necessary to participate in healthcare networks and deliver services within the organization. The Credentialing Specialist works closely with providers, health plans, regulatory agencies, and internal departments to ensure timely and accurate credentialing activities while maintaining compliance with applicable regulations and accreditation standards.

The ideal candidate possesses strong organizational, communication, and problem‑solving skills, along with a thorough understanding of healthcare credentialing regulations, Medicare enrollment requirements, and provider data management.

• Coordinate and process initial credentialing, recredentialing, privileging, and provider enrollment applications.
• Verify provider credentials through primary source verification, including licensure, education, training, board certification, employment history, malpractice coverage, and professional references.
• Ensure providers meet all credentialing requirements and maintain compliance with organizational, federal, state, and payer standards.
• Prepare, submit, track, and maintain Medicare, Medicaid, and commercial payer enrollment applications and revalidations.
• Maintain provider records and databases, ensuring accuracy and completeness of credentialing documentation.
• Monitor expiration dates for licenses, DEA registrations, board certifications, malpractice insurance, and other required credentials to ensure timely renewals.
• Conduct sanctions screening and exclusion monitoring through OIG, SAM, state exclusion databases, and other regulatory sources.
• Communicate with healthcare providers, health plans, hospitals, and regulatory agencies regarding credentialing and enrollment requirements.
• Assist providers with completing credentialing and enrollment applications and resolving documentation deficiencies.
• Ensure compliance with CMS, NCQA, Joint Commission, URAC, payer, and state regulatory requirements.
• Maintain confidentiality of provider information and adhere to HIPAA regulations.
• Prepare reports and maintain credentialing tracking logs to ensure timely processing and compliance.
• Participate in credentialing audits, accreditation reviews, and compliance initiatives.
• Stay current on changes to credentialing regulations, payer requirements, and industry best practices.
• Collaborate with internal departments to support provider onboarding and network participation.
• Perform other related duties as assigned.

• Associate or bachelor’s degree in healthcare administration, Business Administration, Human Resources, or a related field preferred.
• Minimum of 2–3 years of provider credentialing experience in a healthcare organization, medical group, hospital, or Medicare‑managed care environment.
• Thorough knowledge of CMS regulations, Medicare enrollment requirements, and provider credentialing standards.
• Experience credentialing and recredentialing physicians, nurse practitioners, physician assistants, and ancillary healthcare providers.
• Proficiency with CAQH, PECOS, NPPES, Medicare enrollment applications, and provider data management systems.
• Familiarity with NCQA, URAC, Joint Commission, and state regulatory requirements related to provider credentialing and compliance.
• Knowledge of Florida healthcare licensing requirements and state‑specific credentialing regulations.
• Experience conducting primary source verification, license monitoring, sanctions screening, and exclusion checks through OIG, SAM, and state exclusion…