Credentialing Specialist

Credentialing Specialist

Job Overview:

We are seeking a highly organized and detail-oriented Credentialing Specialist with specialized knowledge in Medicaid and Managed Care Organizations (MCOs). The Credentialing Specialist will be responsible for managing and processing credentialing documentation for healthcare providers, ensuring compliance with state and federal regulations. This role requires expertise in Medicaid regulations, MCO credentialing processes, and familiarity with Medicare credentialing. The ideal candidate will have 1-3 years of experience, exhibit exceptional attention to detail, and be able to manage credentialing documentation with accuracy.

Key Responsibilities:

• Medicaid and MCO Credentialing:
  
  
  
  • Manage the credentialing and re-credentialing process for healthcare providers, ensuring compliance with Medicaid regulations and MCO requirements.
  
  
  • Collect, verify, and process credentialing documentation for providers.
  
  
  • Maintain up-to-date knowledge of MCO policies and Medicaid credentialing requirements.
  
  
  
  


• Medicare Credentialing:
  
  
  
  • Oversee the Medicare credentialing process for healthcare providers, ensuring adherence to federal guidelines.
  
  
  • Ensure providers meet all necessary qualifications for Medicare participation.
  
  
  
  


• Regulatory Compliance:
  
  
  
  • Stay updated on relevant Medicaid, MCO, and Medicare regulations and guidelines.
  
  
  • Ensure compliance with state and federal laws governing credentialing processes.
  
  
  
  


• Documentation Management:
  
  
  
  • Collect, review, and accurately maintain credentialing documentation, including licenses, certifications, and background checks.
  
  
  • Track credentialing timelines, ensuring timely renewals of provider credentials and licenses.
  
  
  • Ensure documentation is audit-ready and compliant with all regulatory requirements.
  
  
  
  


• Communication & Collaboration:
  
  
  
  • Work closely with internal teams and external stakeholders to ensure a smooth credentialing workflow.
  
  
  • Serve as the primary point of contact for inquiries related to credentialing.
  
  
  
  


• Data Management:
  
  
  
  • Use credentialing software to manage, update, and track provider credentialing data.
  
  
  • Conduct regular audits of credentialing files to maintain data accuracy.
  
  
  
  

Qualifications:

Associate's or Bachelor's degree in healthcare administration, business administration, or a related field preferred.

Skills:

• Strong understanding of Medicaid regulations and MCO credentialing requirements.


• Knowledge of Medicare credentialing processes.


• Attention to detail and excellent organizational skills.


• Strong written and verbal communication skills.


• Ability to handle multiple tasks and meet deadlines.


• Proficiency in credentialing software and systems.