Credentialing Specialist

JOB SUMMARY

The Credentialing Specialist is responsible for coordinating initial credentialing and recredentialing activities for practitioners and other healthcare providers in accordance with organizational policies, payer requirements, and applicable accreditation/regulatory standards. This role performs primary source verification, monitors licensure and sanctions/exclusions, and maintains complete and audit‑ready credentialing files to support timely provider onboarding and ongoing compliance.

The Credentialing Specialist is responsible for coordinating initial credentialing and recredentialing activities for practitioners and other healthcare providers in accordance with organizational policies, payer requirements, and applicable accreditation/regulatory standards. This role performs primary source verification, monitors licensure and sanctions/exclusions, and maintains complete and audit‑ready credentialing files to support timely provider onboarding and ongoing compliance.

Education Minimum:
High School diploma or equivalent

Experience Minimum:
One year of experience in credentialing, provider enrollment, medical staff services, or a related healthcare administrative role. Preferred:
Two or more years of experience performing primary source verification and managing credentialing files in a medical group, hospital, IPA, MSO, or health plan.

• Strong organizational and time-management skills with the ability to manage multiple credentialing files and deadlines simultaneously.
• Effective verbal and written communication skills, including professional follow-up with providers and internal stakeholders.
• Proficiency with credentialing systems, databases, and standard office software (e.g., Microsoft Office).
• Knowledge of primary source verification methods and common credentialing documentation requirements.
• Understanding of payer credentialing requirements and delegated credentialing concepts (as applicable).
• Ability to identify discrepancies or red flags and elevate appropriately while maintaining documentation standards.
• Knowledge of HIPAA and confidentiality requirements related to provider files and sensitive information.
• Ability to work independently while collaborating effectively with interdisciplinary teams and maintaining attention to detail.

The physical, mental, and environmental demands described here are representative of those required to successfully perform the essential functions of this job. Work is primarily performed in a standard office or hybrid office environment and requires prolonged periods of sitting, frequent use of computers, telephones, and office equipment. The role requires sustained mental concentration, attention to detail, and the ability to review and verify credentialing documentation accurately.

Occasional lifting or moving of materials up to approximately 15–20 pounds may be required. This role requires the ability to communicate effectively with providers, staff, and external partners, and to maintain confidentiality of sensitive credentialing information.