Credentialing Specialist

POSITION SUMMARY

The Credentialing Specialist performs advanced administrative work related to the organization’s provider credentialing and enrollment activities across multiple states and payer types. This role is responsible for managing complex credentialing functions that support the organization’s clinical operations, regulatory compliance, and revenue continuity. The position requires the regular use of analysis, interpretation, and independent judgment in applying payer, regulatory, and accreditation standards and in addressing non-routine credentialing issues that have operational or compliance impact.

PRIMARY RESPONSIBILITIES
Manage the full lifecycle of provider credentialing and recredentialing activities across commercial and government payers, ensuring alignment with organizational objectives, regulatory standards, and payer requirements.

Analyze, interpret, and apply payer, CMS, and regulatory credentialing criteria to varied provider circumstances; assess complex or non-standard situations and determine appropriate actions to maintain compliance and participation.

 

Supports the collaborative agreement process through administrative coordination, documentation tracking, and communication, ensuring all actions follow defined escalation and approval protocols.

Independently evaluate credentialing files to identify discrepancies, gaps, or risks, and address issues through appropriate resolution methods consistent with organizational and regulatory expectations.

Serve as an internal resource on credentialing standards and enrollment requirements, providing guidance to leadership, providers, and cross-functional partners regarding credentialing status, risks, timelines, and operational impact.

Monitor credentialing outcomes, payer feedback, and processing trends; identify systemic issues and recommend enhancements to workflows, documentation standards, or controls to improve effectiveness and audit readiness.

Coordinate and conduct communications with payer representatives, CMS, and external organizations to resolve credentialing matters that require judgment, clarification, or interpretation of requirements.

Maintain and oversee credentialing data within applicable systems and platforms, ensuring integrity, consistency, and compliance across multiple jurisdictions.

 

Contribute to and support credentialing-related initiatives, including process redesign, system enhancements, regulatory changes, and organizational growth activities.

QUALIFICATIONS
Bachelor’s degree preferred; equivalent combination of education and substantial credentialing experience may be considered in lieu of degree.
Demonstrated experience with provider credentialing and enrollment processes, including commercial payers and government programs.
Advanced working knowledge of credentialing platforms and databases (e.g., CAQH, PECOS, Modio, VerityStream, Cactus).
Strong analytical skills with the ability to evaluate complex information and apply standards across varying circumstances.
Ability to work independently on non-routine matters and exercise judgment consistent with regulatory and organizational expectations.
High level of professionalism, confidentiality, and compliance with HIPAA requirements.

The anticipated salary range for this role is $50K-55K annualized. This remote position follows a location-based compensation structure. The posted salary range represents the potential pay range across various U.S. geographic markets. Actual compensation will be determined based on the candidate’s primary work location, experience, qualifications, and internal equity considerations, in accordance with applicable pay transparency laws.