Senior Credentialing Specialist

Overview

The Senior Credentialing Specialist is an experienced, hands-on credentialing professional who manages complex provider credentialing, recredentialing, payer enrollment and related onboarding work while serving as a departmental subject-matter resource. The role conducts and coordinates background screening, resolves escalated issues, strengthens standardized workflows and quality controls, and assists the Director of Credentialing and department lead with workload planning, training, reporting and special projects. This position supports accurate, timely and compliant provider readiness but does not independently make final credentialing decisions or exercise formal supervisory authority unless specifically delegated.

Responsibilities

• Manage a portfolio of complex or high-priority initial credentialing, recredentialing, payer enrollment, roster, revalidation and provider-data maintenance activities across assigned providers, groups, payers and states.
• Conduct and document provider background and screening activities, which may include criminal background checks, identity and exclusion screening, professional-license and disciplinary research, National Practitioner Data Bank queries, OIG and SAM reviews, and other checks required by law, payer contract or company policy.
• Review applications, attestations, primary-source verifications and supporting documentation for completeness, consistency, timeliness and potential adverse information; investigate discrepancies and prepare concise findings for appropriate escalation.
• Troubleshoot complex enrollment, credentialing and provider-data issues by researching payer and regulatory requirements, identifying root causes, coordinating corrective action, and maintaining clear documentation through resolution.
• Serve as an escalation resource for Credentialing Specialists and internal partners; provide practical guidance on established procedures, payer requirements, documentation standards and system workflows.
• Partner with the Director of Credentialing and department lead to assess work queues, deadlines, aging, staffing capacity and business priorities; recommend assignments or rebalancing and help coordinate workload coverage without assuming formal personnel-management authority.
• Develop, document and maintain standardized operating procedures, job aids, templates, checklists and quality controls. Support implementation through communication, training and follow-up review.
• Perform routine quality audits of credentialing and enrollment files, system data and work products; identify recurring errors, trends and control gaps; and recommend corrective or preventive action.
• Support onboarding, cross-training and ongoing development of team members by demonstrating processes, answering questions, reviewing work and providing constructive feedback to departmental leadership.
• Maintain accurate provider profiles, statuses, expirables, work queues, notes and source documentation in CredentialStream and other designated systems. Promote consistent data definitions and documentation practices.
• Monitor licenses, certifications, malpractice coverage, exclusions, sanctions, revalidations and other time-sensitive requirements; promptly address or escalate conditions that may affect participation, billing or provider scheduling.
• Prepare operational reports and dashboards on volume, aging, turnaround time, accuracy, barriers and completion status; translate findings into practical workload or process recommendations.
• Assist with internal reviews, payer or delegated credentialing audits, accreditation readiness, credentials committee preparation and responses to audit findings or corrective action plans.
• Communicate professionally with providers, payers, facilities, vendors and internal departments to obtain information, resolve barriers, set expectations and provide reliable status updates.
• Protect confidential and sensitive information and comply with HIPAA, privacy, information-security, record-retention and company policies, including appropriate handling and disclosure of background-screening and credentialing information.
• Stay current on relevant Medicare, Medicaid, commercial payer, NCQA, federal and state requirements; evaluate operational impact and help translate changes into departmental procedures.
• Lead or support special projects, system testing, data cleanup, payer initiatives and continuous-improvement efforts as assigned.
• Promptly report suspected violations of law or company policy and perform other duties reasonably related to the position.
• Actively supports and complies with all components of the compliance program, including training and reporting of suspected violations of law and Company policy.
• Maintains confidentiality of all information; abides with HIPAA and PHI guidelines at all times.
• To work remotely, it is expected you will have a reliable, nonpublic high-speed internet connection with sufficient bandwidth to participate in all work-related activities. Any interruptions in service should be immediately reported to your manager.  
• Reacts positively to change and performs other duties as assigned.

Qualifications

• High school diploma or equivalent required.
• At least four years of progressive healthcare credentialing, payer enrollment, provider-data or closely related experience, including responsibility for complex cases; equivalent combinations of education and relevant experience may be considered.
• Demonstrated knowledge of primary-source verification, provider background and exclusion screening, initial and ongoing monitoring, recredentialing, Medicare/Medicaid enrollment and commercial payer processes.
• Demonstrated ability to analyze discrepancies, interpret payer or regulatory guidance, identify root causes and carry complex issues through resolution with limited supervision.
• Experience creating or improving procedures, job aids, checklists, quality controls or training materials.
• Strong organizational, prioritization and workload-management skills, including the ability to manage multiple deadlines and shifting business priorities.
• Strong written and verbal communication skills and the ability to provide clear guidance, feedback and status reporting to providers, peers and leadership.
• Proficiency with Microsoft 365 applications, including Outlook, Word and Excel, and working knowledge of credentialing, payer and document-management systems.
• Ability to handle confidential and sensitive information with discretion and sound judgment.
• Associate or bachelor's degree in healthcare administration, business or a related field preferred.
• Five or more years of provider credentialing, payer enrollment, managed-care or medical-services experience in a multi-state or multi-specialty environment preferred.
• Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) certification preferred.
• Experience with CredentialStream or another enterprise credentialing platform and with CAQH, NPPES, PECOS and state Medicaid enrollment systems preferred.
• Experience supporting delegated credentialing, NCQA-aligned operations, audit preparation, credentials committee processes, process improvement, system implementation or data-quality initiatives preferred.
• Experience informally mentoring, training or serving as a subject-matter resource for credentialing staff preferred.

We will only employ those who are legally authorized to work in the United States. Any offer of employment is conditional upon the successful completion of a background investigation and drug screen.

We are an equal opportunity employer.