Credentialing Specialist

JOB TITLE: Credentialing Specialist 
FLSA STATUS (Exempt/Non-Exempt): Non-Exempt 
SUPERVISION RECEIVED: Reports to Credentialing Manager 
SUPERVISION EXERCISED: None 

GENERAL STATEMENT OF DUTIES 

Responsible for performing day-to-day credentialing, recredentialing, licensing, privileging, and payer enrollment activities for Premier and Philadelphia Hand to Shoulder Center physicians and other healthcare providers. Ensures credentialing applications and supporting documentation are complete, accurate, and submitted within required timeframes. Maintains current provider information within credentialing systems, monitors licenses, certifications, and other expirable credentials, and provides timely follow-up with physicians/providers, hospitals, health plans, and other organizations. Works closely with the Credentialing Manager and internal departments to support timely provider onboarding and maintain ongoing credentialing compliance. 

ESSENTIAL FUNCTIONS 

• Completes and processes initial credentialing and recredentialing applications for physicians and other healthcare providers.  

• Collects, reviews, and maintains required credentialing documentation, including professional licenses, board certifications, DEA registrations, professional liability insurance, education, training, work history, and other required credentials.  

• Performs primary source verification of provider credentials in accordance with applicable requirements.  

• Obtains and reviews National Practitioner Data Bank (NPDB), Office of Inspector General (OIG), state licensing board, and other applicable verification or sanction information.  

• Completes and maintains provider enrollment applications for Medicare, Medicaid, commercial health plans, and other applicable payers.  

• Coordinates hospital and facility credentialing, privileging, and reappointment applications, as applicable.  

• Maintains accurate and current provider information within CAQH and other applicable credentialing, payer, hospital, and provider databases.  

• Tracks and monitors provider licenses, DEA registrations, board certifications, professional liability insurance, and other expirable credentials to ensure timely renewal.  

• Contacts physicians/providers to obtain outstanding applications, signatures, attestations, documentation, and other information required to complete credentialing activities.  

• Provides consistent and timely follow-up on outstanding credentialing and recredentialing applications.  

• Communicates credentialing status, outstanding requirements, and potential delays to the Credentialing Manager and other appropriate stakeholders.  

• Identifies incomplete, inconsistent, or potentially concerning credentialing information and escalates issues to the Credentialing Manager for review.  

• Ensures hospitals, health plans, medical groups, and other applicable entities receive required provider demographic and practice updates.  

• Processes provider demographic changes, additions, terminations, and other updates with applicable payers, hospitals, facilities, and credentialing organizations.  

• Assists with provider network termination activities when providers leave the organization.  

• Maintains accurate electronic credentialing files and ensures documentation is appropriately filed, scanned, indexed, and entered into applicable credentialing systems.  

• Ensures provider credentialing records are complete, accurate, current, confidential, and audit-ready.  

• Monitors credentialing and enrollment timelin