Sr Credentialing Specialist

Our vision is a world of peaceful relationships with food, weight, and body image, where everyone with an eating disorder can experience recovery. We believe that exceptional, individualized care leads to lasting recovery from eating disorders. That’s why our teams are comprised of compassionate, dedicated professionals from a variety of backgrounds who collaborate to provide the very best evidence-based care for our clients at all levels of care. 

Position Overview:  

The Senior Credentialing Specialist is responsible for managing provider credentialing, credentialing committee, and ensuring compliance with state, federal, and insurer requirements. Summary duties for this position include initiating and maintaining provider credentialing with insurers as well as responding to any inquiries from payors, providers, billing, client services, IT, and liability insurance carriers.   

Duties and Responsibilities:  

• Educate new providers and any employees who are already credentialed with insurers on the credentialing process and assist with obtaining applicable state licensure 

• Assist, tracks, and submits appropriate documentation for credentialed employees to ensure timely renewal of their licensure 

• Ensure all providers are credentialed with applicable insurers via credentialing applications submitted to insurers upon receiving complete and verified provider credentialing materials 

• Collect, review, and verify credentialing documents including licenses, certifications, education, training, and work experience 

• Submit and track credentialing and re-credentialing provider applications as well as work with Payor Relations to complete and submit facility credentialing packets 

• Maintain current and accurate data for all providers, including tracking of license, DEA certificates, professional liability insurance, and certification expiration dates 

• Ensure compliance with federal, state, and accreditation requirements (e.g. NCQA, JCAHO) 

• Serve as primary credentialing liaison for the organization, interacting with insurers, malpractice carriers, credentialing agents, and application software representatives 

• Utilize credentialing portals (e.g. CAQH, NPPES, PECOS, etc.) required to request initial credentialing, re-credentialing, and communicate changes related to providers and the group practice 

• Update provider data sheet for entire organization and all insurance companies within internal HR systems and any credentialing software  

• Keep up to date on all credentialing requirements per provider licensure as well as maintaining knowledge of health plan specific requirements 

• Track malpractice insurance expirations and communicate with malpractice carrier of any potential malpractice threat or update to provider malpractice history 

• Collaborate with billing team to resolve insurance rejections related to credentialing 

• Provide weekly updates on credentialing status and approvals 

• Responsible for all aspects of credentialing committee including preparation of documentation, running the committee meeting, and follow up items 

• Attend all assigned trainings and required meetings 

• Maintain confidentiality of all provider information 

 

Education Qualifications: 

• Associate degree; Bachelor's degree is preferred  

 Professional Qualifications: 

• 3 – 5 years of credentialing and provider enrollment experience 

• 3 – 5 years of credentialing committee experience 

 Workplace Environment: