Credentialing Specialist

Job Summary:

The Credentialing Specialist plays a vital role in ensuring that healthcare providers meet the necessary qualifications and standards to deliver quality care. This position involves verifying credentials, maintaining accurate records, and ensuring compliance with regulatory requirements within a medical office or managed care environment. The ideal candidate will possess a strong understanding of medical terminology and credentialing standards, along with excellent organizational skills.

Key Responsibilities:

• Verify the credentials of healthcare providers, including education, training, licensure, and certifications.
• Maintain up-to-date records in compliance with regulatory standards and internal policies.
• Conduct primary source verification to ensure accuracy and authenticity of credentials.
• Collaborate with medical staff and administration to facilitate the credentialing process.
• Monitor expiration dates of licenses and certifications to ensure timely renewals.
• Assist in the preparation of reports related to credentialing activities for management review.
• Stay informed about changes in regulations and standards related to credentialing in managed care settings.
• Submits provider enrollment applications to all network payors
• Ensures all provider CAQH, NPI, and state requirements are met and updated annually
• Submits payor requests for network participation
• Build knowledge base for payor requirements and forms.
• Works closely with Billing Department to respond to any claim denials or benefit issues related to provider credentialing.
  

Qualifications:

• Must have at least 1 to 2 years' experience as a Credentialing Specialist
• Knowledgeable in End-to-end credentialing process.
• Okay to fully work onsite in Eastwood Quezon City
• Proficiency in medical terminology is essential for effective communication and documentation.
• Previous experience in a medical office or healthcare setting is preferred.
• Familiarity with credentialing standards and processes within managed care environments is advantageous.
• Strong attention to detail and organizational skills to manage multiple tasks efficiently.
• Excellent communication skills, both verbal and written, for effective interaction with healthcare professionals.
• Ability to work independently as well as part of a team, demonstrating initiative and problem-solving capabilities.