Provider Credentialing Specialist II Compliance & Paneling

Qualifacts Systems Inc.; Tampa (FL); Hybrid; USD 52,000 - 70,000; Full time

Job summary

Qualifacts Systems Inc. is seeking a Provider Credentialing Specialist to manage credentialing for physicians, allied health, and other practitioners.

The role is hybrid, based in Nashville or Tampa, with remote candidates not considered, and involves regulatory and accreditation compliance across Behavioral Health and related fields. You will maintain practitioner databases, coordinate insurance paneling with payers, and advise on renewal procedures while developing credentialing standards and

Qualifications

• Proven experience in provider credentialing and insurance paneling.
• In-depth knowledge of industry's standards and regulations.
• Provider Credentialing Specialist certification through NAMSS preferred.

Responsibilities

• Keeps abreast of regulatory developments in the Behavioral Health, Primary Care, and Medical Staff Services industries.
• Maintains compliance with regulatory and accrediting bodies.
• Works collaboratively with leadership in the development and implementation of credentialing processes and procedures.
• Credentialing of physicians, allied health, and other practitioners.
• Insurance paneling of facilities, physicians, allied health, and other practitioners.
• Collects and maintains an accurate practitioner database and analyzes verification information.
• Collects and maintains records in licenses, credentials, and insurance contracts.
• Monitors Partner/Customer's providers' credentials and licenses.
• Works collaboratively with Partners/Customers to advise on renewal procedures.
• Work collaboratively with Partners/Customers to ensure timely completion of credentialing processes.
• Releases information to agencies and members of the public as required by law.
• Escalates identified credentialing risks to Billing Manager and Partner/Customer leadership.
• Has a subject matter expertise level provider credentialing and processes.
• Develops and maintains credentialing processes and standards for the department.
• Keeps abreast of credentialing requirements for Joint Commissions and CARF.
• Keeps abreast of insurance paneling requirements for Medicare, Medicaid, and Commercial payers.
• Assists with the development and operations of a customer call center.
• Provides credentialing consultations/trainings as requested.

Skills

Provider credentialing

Insurance paneling

Regulatory knowledge

Communication skills

Organizational skills

Education

NAMSS certification preferred

Job description

Qualifacts Systems Inc. is seeking a Provider Credentialing Specialist to manage credentialing for physicians, allied health, and other practitioners.

The role is hybrid, based in Nashville or Tampa, with remote candidates not considered, and involves regulatory and accreditation compliance across Behavioral Health and related fields. You will maintain practitioner databases, coordinate insurance paneling with payers, and advise on renewal procedures while developing credentialing standards and