Credentialing Specialist

Part‑time, non‑benefit eligible

Position Function Summary

Under the direction of the Director of HR, the Credentialing Specialist verifies and processes the qualifications of medical professionals to ensure they meet regulatory requirements, including ensuring that all providers are appointed, credentialed, and privileged for the clinic and with insurance plans and hospitals and ensures that current licenses and certifications for all providers are in compliance with State and Federal standards.

• Conducts primary sources verification to confirm the accuracy of a healthcare provider’s education background, licenses, certifications, and work experience.
• Compiles and submit credentialing and re-credentialing applications to insurance companies and healthcare facilities.
• Keep accurate and up-to-date records in credentialing software and databases and update information on provider directories.
• Ensure all documentation and provider credentials comply with federal, state and industry standards and regulations, such as those from NCQA, TJC, FTCA, HRSA and other Federally Qualified Health Center standards and regulations.
• Monitor license expiration dates and initiate the renewal process to prevent lapses in service.
• Serve as a point of contact for providers to request missing information or clarify discrepancies and communicate with internal departments.
• Prepare files for credentialing committees and audits and respond to payer requests for information.
• Assist newly hired practitioners in the application process for required NM state licenses.
• Complies and tabulates various data required to primary source verifications entities and insurance providers; coordinates with Billing department to ensure that credentialing is current. Communicates credentialing variances to Operations Department/PSRs.
• Supports Quality manager in attesting providers for Meaningful use.
• Maintains copies of current provider state licenses, DEA and CDS certificates, malpractice coverage, board certifications, and any other documents required to maintain provider privileging/credentialing.
• Other duties as assigned.

• High school diploma or equivalent, with an associate’s degree in a related field preferred. May have any equivalent combination of experience, training, and/or education as approved by Human Resources.
• Professional certifications like Certified Provider Credentialing Specialist (CPCS) preferred.
• Strong computer skills and knowledge of medical terminology are essential.
• Proficiency with credentialing software and databases is a key requirement.
• Excellent attention to detail, organizational skills, and the ability to manage time effectively are critical for success.
• Strong written and verbal communication skills are necessary for interacting with providers and internal teams.
• Knowledge of industry regulations and standards (e.g., NCQA, TJC) is important.

Bargaining Unit Position

Union:

Non-Union: X

La Familia offers opportunities for employment in the fields of medicine, nursing, dentistry, health education, and other support services. We are an equal opportunity employer.