Job Description

Position Summary

The Credentialing Specialist will be responsible for performing tasks related to the credentialing of new providers, including document collection, verification, and file maintenance. The role ensures that all credentialing documentation is confidential and securely maintained, while assisting providers and facilities in understanding and adhering to credentialing policies and procedures.

Key Responsibilities

• Verification of Credentials: Confirm that healthcare providers (e.g., physicians, nurses, therapists) have valid and current licenses, certifications, education, and training. Verify board certifications, malpractice history, and work experience.
• Compliance and Regulatory Oversight: Ensure all providers meet the requirements of regulatory agencies, hospitals, and insurance networks. Maintain compliance with standards from organizations such as The Joint Commission (TJC) or NCQA.
• Enrollment and Privileging: Manage applications for providers to be enrolled with insurance payers (so they can bill for services). Handle the hospital privileging process, which authorizes providers to perform specific procedures within a facility.
• Record Maintenance: Maintain accurate and up-to-date credential files for each provider. Track expiration dates for licenses, certifications, and re-credentialing timelines.
• Communication and Coordination: Act as a liaison between providers, HR, medical staff offices, and payers. Communicate with the state licensing

Skills & Qualifications

• Excellent communication and organizational skills.
• Experience with provider credentialing processes and procedures.
• Strong computer skills; proficient in MS Office.
• Knowledge of credentialing systems (e.g., CACTUS) preferred.
• Familiarity with healthcare credentialing policies and compliance standards preferred.

Education

• High School diploma or equivalent required.
• Bachelor’s degree preferred.

Pride Health offers eligible employees comprehensive healthcare coverage (medical, dental, and vision plans), supplemental coverage (accident insurance, critical illness insurance, and hospital indemnity), 401(k)-retirement savings, life & disability insurance, an employee assistance program, legal support, auto, home insurance, pet insurance, and employee discounts with preferred vendors.

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