Credentialing Specialist

Position Summary:

The Credentialing Specialist manages the administrative processing, verification, and maintenance of healthcare provider qualifications. This role guarantees full compliance with NCQA standards, state/federal regulations, Medicare/Medicaid guidelines, and Community Care Plan (CCP) policies.

 Essential Duties and Responsibilities:

• Manage Full Lifecycle: Process provider credentialing from inception to final committee review.
• Primary Source Verification: Validate education, training, board certifications, and Florida state licenses.
• Background Screening: Query National Practitioner Database (NPDB), System for Award Management (SAM), the Office of Inspector General (OIG), the Agency for Healthcare Administration (AHCA), Social Security Death Master File (DMF), NPI registry, and the Florida Medicaid Provider Master List (PML). 
• Document Auditing: Verify hospital affiliations, employment history, malpractice insurance, and Tax IDs.
• Investigation: Resolve application discrepancies, employment gaps, and adverse background information.
• Database Ownership: Maintain accurate provider records in the system according to internal data standards.
• Continuous Monitoring: Track system alerts for provider sanctions, exclusions, and expiring credentials.
• Reporting: Elevate complex compliance issues and risks to Credentialing Leadership.
• Cross-Functional Collaboration: Partner with Provider Operations and Data Management to streamline network onboarding.
• Committee Prep: Assemble complete, audited provider files for the CCP Credentialing Committee.
• Stakeholder Support: Serve as the main point of contact for internal and external credentialing status inquiries.
• Professional Development: Maintain knowledge of evolving healthcare legislation and NCQA standards.
• Operational Success: Contributes to miscellaneous operational tasks to ensure overall team and organizational goals are met.

This job description in no way states or implies that these are the only duties performed by the employee occupying this position. Employees will be required to perform any other job-related duties assigned by their supervisor or management.

Qualifications: 

• Degree: Associate’s degree or an equivalent blend of education and experience.
• Credentialing: 3+ years in healthcare credentialing or provider onboarding.
• Industry Knowledge: Working knowledge in managed care or healthcare environment.
• Data Management: 3+ years of experience managing high-volume databases or records.
• Technical Proficiency: Microsoft Office (Word, Excel) and standard healthcare databases (Epic Tapestry is a plus).
• Project Management: Project management certification or proven organizational skills to manage high-volume application workflows and strict deadlines.

Skills and Abilities: 

• Ability to analyze legal documents, technical journals, and complex data sets.
• Self-motivated worker who exercises independent judgment and problem-solving.
• Professional verbal and written English communication skills.
• Define problems, collect data, establish facts, and draw valid conclusions.
• Responds to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
• Maintains strict confidentiality and handles sensitive information.
• Ability to learn new applications to function effectively in a remote work environment.
• Establish priorities with independent coordination of day-to-day aspects. 

 Physical Demands: 

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to sit, use hands, reach with hands and arms, and talk or hear. The employee is frequently required to stand, walk, and sit. The employee may occasionally be required to stoop, kneel, crouch or crawl. The employee may occasionally lift and/or move up to 15 pounds.

Work Environment: 

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of the job. The environment includes work inside/outside the office, travel to other offices, as well as domestic travel. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. The noise level in the work environment is usually moderate.

We are an equal opportunity employer who recruits, employs, trains, compensates and promotes regardless of age, color, disability, ethnicity, family or marital status, gender identity or expression, language, national origin, physical and mental ability, political affiliation, race, religion, sexual orientation, socio-economic status, veteran status, and other characteristics that make our employees unique. We are committed to fostering, cultivating, and preserving a culture of diversity, equity, and inclusion.

Background Screening Notice:
In compliance with Florida law, candidates selected for this position must complete a Level 2 background screening through the Florida Care Provider Background Screening Clearinghouse.

The Clearinghouse is a statewide system managed by the Agency for Health Care Administration (AHCA) and is designed to help protect children, seniors, and other vulnerable populations while streamlining the screening process for employers and applicants.

Additional information is available at:
🔗 hhttps://info.flclearinghouse.com