Credentialing Specialist (Finance)

Credentialing Specialist

Job Summary
The Credentialing Specialist plays a vital role in ensuring physicians meet all licensing, certification, and regulatory standards required to practice within a healthcare facility. This position demands a high degree of discretion and responsibility, as it involves handling highly sensitive personal information, including home addresses, driver's license numbers, and Social Security numbers, while maintaining strict confidentiality.

The Credentialing Specialist is responsible for overseeing the credentialing process with health plans, enrolling and managing EDI payer contracts, and meticulously tracking and updating documentation. In addition, this role includes maintaining comprehensive physician immunization records, ensuring the accurate management of surgical and hospital privileges for all physicians, and ensuring that all credentials and privileges are kept current. The Specialist also serves as the primary point of contact for physicians and payers, ensuring seamless communication and timely resolution of credentialing-related matters. By remaining informed on industry standards and regulatory changes, the Credentialing Specialist ensures the facility's adherence to compliance requirements, contributing to the overall safety and quality of patient care delivered.

This is a Remote position; however, all candidates considered for this position must currently reside within Southern California.

Duties/Responsibilities

Credentialing application processing: Collect, review, and verify all required documentation for provider credentialing applications, including medical licenses, certifications, malpractice insurance, and practice history.?

Background checks: Conduct thorough background checks on providers, including criminal history and disciplinary actions, to ensure suitability for practice.?

Primary source verification: Contact primary sources like medical schools, hospitals, and licensing boards to verify the accuracy of provider credentials.?

Data entry and maintenance: Maintain accurate and up-to-date provider information within the credentialing database, including license expiration dates and clinical privileges.?

Credentialing committee support: Prepare reports and presentations for the credentialing committee regarding provider credentialing status and any potential issues.?

Provider communication: Communicate with healthcare providers regarding credentialing status, missing documentation, and necessary updates.?

Compliance monitoring: Stay abreast of changing regulatory requirements and ensure the credentialing process aligns with all applicable laws and standards.?

Renewal tracking: Monitor provider license and certification expiration dates and initiate renewal processes to prevent lapses in credentialing.?

EDI: Enroll and maintain payor contracts for all EDI transactions.