Credentialing Specialist

NeighborHealth Center, Inc.; Raleigh (NC); On-site; USD 55,000 - 75,000; Full time

Job summary

NeighborHealth Center is seeking a Credentialing Specialist to manage credentialing and recredentialing for our providers and ensure enrollment with participating health plans. The role includes primary source verification, CAQH maintenance, and data integrity, with collaboration across HR and Billing to ensure timely handoffs and issue resolution.

Ideal candidates have an associate degree (or equivalent) and at least 3 years of credentialing experience in a managed care setting, plus

Qualifications

• Associate degree preferred or equivalent combination of education and/or experience.
• Minimum 3 years’ experience in provider credentialing in a managed care setting.
• Experience with medical and professional credentialing processes, policies, and delegated credentialing requirements.

Responsibilities

• Initiate and support provider applications and data import for credential verification.
• Gather, verify, and evaluate confidential provider credentials per guidelines and standards.
• Perform initial credentialing and recredentialing to ensure current credentials and timely handoff of files.
• Respond to provider, client health plan, and internal inquiries promptly.
• Monitor expiring licensure, board, and professional certifications within required timeframes.
• Maintain provider data files using CAQH and submit data for credentialing.
• Ensure accurate data entry to preserve credentialing data integrity.
• Collaborate with HR for smooth credentialing hand-offs.
• Use follow-up to resolve discrepancies identified during credentialing.
• Monitor compliance and alert HR of undisclosed negative findings.
• Review, process, and distribute incoming correspondence related to credentialing.
• Keep HR and Billing informed of credentialing issues.
• Other duties as assigned.

Skills

Computer literacy

Interpersonal relations

Advocacy for diversity

Clear communication

Deadline sensitivity

Confidential information handling

Education

Associate degree

Tools

CAQH

Job description

Description

Position Summary

The Credentialing Specialist is responsible for credentialing and recredentialing NeighborHealth Center providers as well as ensuring enrollment with participating client health plans. Credentialing functions include, but are not limited to, processing credentialing applications, malpractice insurance applications, performing primary source verification, and updating and maintaining the CAQH credentialing database in accordance with internal policies and procedures, client health plan contracts, HRSA guidelines and applicable state and federal requirements.

Principal Duties and Responsibilities

1. Initiate and support the provider application process by sending, receiving, and analyzing Provider documents and data import to determine completeness in preparation for the credential verification process.
2. Responsible for gathering, verifying, and evaluating highly confidential and sensitive health care provider credentials consistent with departmental guidelines and accreditation standards.
3. Efficiently perform all aspects of credentialing verification, including initial credentialing and recredentialing to ensure current credentials and timely handoff and/or review and approval of provider files.
4. Respond to all provider, client health plan, and internal inquiries in a timely manner.
5. Monitor expiring licensure, board, and professional certifications and other expirable documents with provider within the prescribed timeframe.
6. Maintain provider paper and electronic data files utilizing CAQH to submit provided data as required to credential individual providers.
7. Responsible for accurate data entry to ensure the integrity of credentialing information in applicable database(s).
8. Collaborate with HR to facilitate and ensure smooth hand-off during the credentialing process.
9. Use critical thinking skills to conduct follow-up with individual providers and internal and external entities to resolve discrepancies identified during the credentialing process.
10. Compliance monitoring and alert HR of any undisclosed negative findings immediately.
11. Shared responsibility for reviewing, processing, and distributing incoming correspondence (e.g., interdepartmental mail, faxes, and email).
12. Keep HR and Billing Manager informed of potential credentialing or enrollment issues.
13. Other duties as assigned.

Requirements

Required Skills or Abilities*

1. Computer literacy in internet use and Windows environment, including Outlook, Word, and Excel.
2. Ability to cultivate and develop inclusive and equitable working relationships with co-workers and community members.
3. Ability to serve as an advocate for individuals of all ethnicities, genders, ages, and backgrounds.
4. Able to communicate clearly and concisely, both verbally and in written correspondence.
5. Able to work well under tight deadlines and respond to rapidly changing demands and provide efficient follow-up.
6. Capable and comfortable dealing with sensitive and confidential information with discretion and trust.

Required Knowledge, Experience, or Licensure/Registration

1. Ability to work Mondays through Fridays during the routine business hours with scheduled onsite presence required no less than once a week.
2. When working remotely, the ability to work in a private home workspace — where screens and conversations cannot be seen or overheard by others — with a secure, password-protected home internet connection (not shared or public Wi-Fi), sufficient to protect confidentiality at all times.
3. Ability to read, write, speak, and comprehend English fluently as needed to perform essential job functions, including communication, documentation, and safety-related instructions.
4. Associate degree is preferred or an equivalent combination of education and/or experience.
5. Minimum of 3 years’ experience in provider credentialing in a managed care setting.
6. Experience should include responsibility for medical and professional credentialing processes, policies and procedures, and delegated credentialing requirements.

Physical requirements of the Job

With or without reasonable accommodation, this position requires the ability to:

• Sit or stand, often for prolonged periods

This is a full-time, non-exempt position.

* NeighborHealth Center is an Equal Opportunity Employer, dedicated to serving a diverse patient population and building a staff reflective of the communities we serve. We encourage applications from women, minority groups, veterans, and people with disabilities.