Credentialing Specialist II

Summary of Job: The Credentialing Specialist II is responsible for managing and maintaining the credentialing and re-credentialing process for providers. This includes ensuring compliance with regulatory and organizational standards, submitting applications, monitoring renewals, and maintaining accurate provider records. The role requires strong attention to detail, organizational skills, and the ability to manage multiple priorities in a fast-paced environment.

Essential Duties and Responsibilities:
Enrollment Management:
Completes provider credentialing and re-credentialing applications in accordance with payer and regulatory requirements.
Monitors application progress, provides follow-up, and ensures timely completion.
Establishes and maintains provider profiles with the Council for Affordable Quality Healthcare (CAQH).
Licensing & Certification Management:
Completes, processes, and submits state licensing applications to medical boards for new and existing providers.
Renews state medical licenses, hospital privileges, board certifications, DEA registrations, and other required documentation.
Tracks expiration dates and proactively ensures timely renewals to avoid lapses in provider eligibility.
Inbox & Communication Management:
Actively monitor and manage email communications, with a focus on prioritizing time-sensitive issues.
Triage and respond to provider concerns, escalating them to the appropriate departments or personnel as needed.
Enrollment & Compliance:
Enrolls providers with Medicare, Medicaid, and other payer contractors; completes revalidation as required.
Researches and stays current on state licensure and credentialing requirements, regulations, and protocols.
Maintains compliance with RI International’s Code of Conduct and Conflict of Interest policies.
Provider File Management:
Maintains accurate and complete provider files using payer portals, credentialing systems, OneApp Pro, and internal spreadsheets.
Uploads and organizes documentation for ease of access and auditing.

Cross-Functional Collaboration:
Work closely within
human resources, legal, compliance, program leadership, and executive teams to ensure a smooth and integrated credentialing process and establish efficient workflows.
Assist with process transitions as responsibilities shift between internal departments, ensuring continued workflow clarity and support.

Additional Duties:
Understands and adheres to Recovery Innovations compliance standards as they appear in the Code of Conduct and Conflict of Interest Policies.
Keeps abreast of all federal and state regulations and laws and all Recovery Innovations policies as they presently exist and as they change or are modified.
Performs other related duties assigned.

Job Requirements: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed must be representative of the knowledge, skills, minimum education, training, licensure, experience, and/or ability required. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential duties.

Education:
Associate’s or Bachelor’s degree in Healthcare Administration, Business, or a related field preferred.
Years of experience may be taken in account in lieu of formal education.
Experience:
Minimum of two (2) years of experience in behavioral health contracting, provider enrollments, or healthcare administration.
Experience with CMS PECOS, NPPES, Medicaid, and Medicare processes and enrollment procedures.
Skills:
Strong understanding of behavioral health services, billing codes (CPT), and payer requirements.
Proficiency with project management tools (e.g., ClickUp), Microsoft Office Suite, and enrollment systems.
Exceptional organizational, analytical, and interpersonal skills.
Familiarity with healthcare compliance, state-specific Medicaid/Medicare regulations.
Experience working with EHR, healthcare claims systems, and/or credentialing software.
Ability to work independently while managing multiple priorities and deadline
Ability to work independently and handle sensitive information with confidentiality.
Knowledge of insurance payer portals.
Expertise in managed care, insurance plan structures, and provider credentialing requirements.
Demonstrated ability to communicate effectively both verbally and in writing.
Strong ability to prioritize tasks and ensure timely, accurate project completion.
Proficient in accurately calculating figures such as discounts, interest, and percentages.
Ability to maintain confidentiality of sensitive financial information.
Excellent organizational skills with attention to detail.
Experience completing daily work using a work queue or spreadsheet.
Ability to exercise considerable judgment and discretion.
Ability to travel as needed.
Miscellaneous Requirement:
Travel required based on business need.
Ability to maintain a high level of confidentiality (HIPAA guidelines and regulations) and professionalism.
We are a Second-Chance Employer
Must be able to pass a seven-year background check.
Must be able to pass substance abuse testing and/or tuberculous testing (if applicable).
Must be able to obtain designated fingerprinting clearance in applicable states.
Must be able to pass education verification check.
Must be able to pass three-year motor vehicle report and meet minimum eligibility requirements criteria of insurance carrier (if driving is required for this position).