Job Description
The Insurance Credentialing Specialist clerk is responsible for analyzing and processing documents for verification of practitioner’s credentials with emphasis on regulatory compliance, processing accuracy and timeliness of information processed.
Job Duties:
- Complete initial credentialing and recredentialing applications for all hospital-employed providers, including physicians, nurse practitioners, physician assistants, and therapists.
- Manage and submit provider enrollment applications to commercial insurers, Medicare, Medicaid, and managed care organizations (MCOs).
- Track and monitor the status of applications, follow up with payers, and resolve any issues or delays to ensure timely enrollment.
- Maintain accurate credentialing records and databases, including expiration dates for licenses, DEA registrations, board certifications, and liability insurance.
- Collaborate with the Medical Staff Office to ensure compliance with hospital bylaws and Joint Commission standards.
- Work closely with Revenue Cycle teams to ensure provider billing setup is accurate and complete in the hospital’s EHR and billing systems.
- Respond to payer requests for information and documentation in a timely and professional manner.
- Notify appropriate departments and leadership of credentialing updates, including effective dates, plan participation, and payer credentialing status.
- Assist with audits and compliance reviews related to credentialing and payer enrollment.
- Maintain confidentiality of sensitive provider and organizational information.
Education:
High School Diploma or equivalent required; Associate’s or Bachelor’s Degree in Business, Healthcare Administration, or related field preferred.
Training/Experience:
Minimum of 2 years of experience in provider credentialing, payer enrollment, or a related healthcare administrative role required.
Skills/Qualifications:
- Working knowledge of payer credentialing requirements, including Medicare, Medicaid, and commercial plans.
- Familiarity with CAQH, PECOS, NPPES, and other credentialing portals.
- Strong organizational and time management skills with ability to manage multiple priorities.
- Excellent written and verbal communication skills.
- Attention to detail and a high degree of accuracy.
- Ability to work independently and as part of a team.
- Proficiency with Microsoft Office (Word, Excel, Outlook) and credentialing software systems.
Type: Full-time