Credentialing Coordinator

Position Summary:
The Credentialing Coordinator is responsible for ensuring that all providers meet the necessary requirements and are approved to participate in client health plans. This role will work closely with Recruiting, Production, and Education teams, and reports directly to the Manager of Credentialing.

Essential Functions:

• Review and screen initial and reappointment credentialing applications for completeness, accuracy, and compliance with federal, state, local, and NCQA regulations, guidelines, and internal policies.

• Conduct primary source verification and collect/validate documentation to ensure accuracy of all credentialing elements.

• Assess provider qualifications relative to credentialing standards and Signify Health criteria while maintaining confidentiality of protected health information.

• Identify and resolve discrepancies, gaps, or other issues that may impact credentialing and enrollment; escalate concerns to the Credentialing Manager/Supervisor/Director as needed.

• Monitor files for accuracy and compliance with accreditation requirements and organizational quality standards.

• Prepare and provide credentialing information to internal and external stakeholders as appropriate.

• Enter, update, and maintain provider data in the credentialing database with accuracy and adherence to policies and data standards.

• Prepare, issue, track, and follow up on verifications to ensure efficient, high-volume processing within strict timelines.

• Communicate clearly with providers, internal teams, and external clients to resolve day-to-day credentialing issues.

• Stay current on healthcare regulations, accreditation standards, and industry best practices through training, seminars, and professional development.

• Assist with special projects and other credentialing-related tasks as needed.

Qualifications:

• Proven experience in a credentialing role, preferably in a healthcare or managed care environment.

• NAMSS Certification as a Certified Provider Credentialing Specialist (CPCS), or eligibility to obtain within 2 years (preferred).

• Experience with CAQH (preferred).

• Experience with MD-Staff or other credentialing database software (preferred).

• Proficiency in Google Suite (preferred).

• Strong attention to detail, organizational skills, and ability to manage multiple priorities.

• Excellent communication and problem-solving sk ills.