Healthcare Credentialing Specialist

Description
The Healthcare Credentialing Specialist performs healthcare provider credentialing and recredentialing while providing oversight of credentialing workflows, file quality, and timely processing. This role combines hands-on credentialing responsibilities with packet reviews, auditing, quality assurance, and guidance to staff and stakeholders to ensure accurate, complete, and timely provider credentialing.

This position requires a meticulous professional who can manage an individual caseload while monitoring the quality and progress of credentialing activities across the team. The successful candidate brings sound judgment, consistent follow-through, and a disciplined approach to managing competing deadlines and changing priorities.

Key Responsibilities
Manage an individual caseload of initial credentialing and recredentialing files from application intake through submission for review.
Provide day-to-day oversight of credentialing workflows and processes, coordinating priorities and helping address backlogs and processing delays.
Review and audit credentialing packets, including work prepared by others, for accuracy, completeness, consistency, and compliance with applicable credentialing, client, and program requirements.
Perform and document primary source verification of provider qualifications, including licensure, education, training, and certifications, as required.
Identify documentation gaps and discrepancies, obtain missing information, and maintain clear follow-up records to resolve outstanding items promptly.
Complete required background and exclusion checks, document findings, and escalate adverse information or exceptions for appropriate review.
Monitor credentialing progress, turnaround times, and quality standards; communicate workload concerns and deadline risks.
Maintain accurate credentialing databases and organized, audit-ready files, including verification dates, expiration dates, correspondence, and status updates.
Monitor expiring credentials and recredentialing deadlines, initiating follow-up early to help prevent delays or lapses.
Provide guidance and support to credentialing staff and stakeholders, clarify procedures, and assist with staff onboarding and training.
Identify recurring errors and process weaknesses; recommend and implement approved improvements to increase efficiency and accuracy.
Prepare status reports, support audits, and protect confidential provider and organizational information.

Requirements
Education & Experience

Minimum of five years of healthcare provider credentialing experience, including initial credentialing, recredentialing, and primary source verification.
Experience providing credentialing oversight, auditing, or quality assurance while maintaining hands-on responsibility for credentialing work.
Experience coordinating credentialing processes or implementing process improvements.
Experience reviewing work prepared by others, resolving complex documentation issues, and meeting established turnaround times.
Knowledge of CAQH, NCQA, URAC, and government healthcare programs is preferred.
TRICARE credentialing experience is a plus, but is not required.
Required Knowledge, Skills & Abilities
Meticulous attention to detail, with a disciplined approach to reviewing documentation, identifying inconsistencies, and preventing errors.
Strong knowledge of provider credentialing processes, documentation requirements, and verification methods.
Ability to interpret and apply applicable credentialing requirements and client and program procedures.
Strong analytical, organizational, and problem-solving skills.
Ability to balance an individual caseload with workflow oversight, quality reviews, and timely follow-through on team priorities.
Ability to remain composed, exercise sound judgment, and communicate professionally when managing urgent requests, competing deadlines, and changing priorities.
Clear written and verbal communication skills, including the ability to explain requirements, provide constructive feedback, and guide colleagues and stakeholders.
Ability to resolve issues within delegated authority and escalate matters requiring management review or credentialing decisions.
Proficiency with credentialing databases, Microsoft Office applications, and electronic records.
Discretion and sound judgment when handling sensitive and confidential information.