Description
Verify and maintain provider credentials, privileges, and payer enrollments; ensure compliance with accreditation, regulatory, and payer standards; manage credentialing databases; and coordinate with providers and medical staff to support timely onboarding.
- • Address credentialing or privileging issues, discrepancies, complaints, or adverse findings with providers and leadership.
- • Analyze credentialing, privileging, and enrollment data; prepare compliance and expiring-credential reports.
- • Coordinate recredentialing cycles and track expirables such as licenses, DEA, board certifications, and insurance.
- • Conduct primary source verification of education, training, licenses, board certifications, and malpractice history.
- • Run background and sanction checks, including NPDB, OIG/SAM, Medicare/Medicaid exclusions, and state disciplinary actions.
- • Collaborate with medical staff leadership to develop and implement credentialing and privileging policies and criteria.
- • Communicate application status, missing items, and timelines to providers and stakeholders.
- • Develop and refine credentialing workflows to meet organizational and payer turnaround targets.
- • Prepare, compile, and process credentialing and privileging applications and related documentation.
- • Inform providers of privileging requirements, payer enrollment steps, and onboarding expectations.
- • Interpret and explain Joint Commission, NCQA, CMS, and state licensing requirements to staff and providers.
- • Collect and review credentialing applications and CVs for completeness, accuracy, and gaps in employment or training.
- • Maintain provider credentialing files, rosters, directories, and privileging forms in the credentialing system.
- • Stay current with accreditation standards and regulatory changes affecting credentialing and enrollment.
- • Perform sanctions and malpractice claims queries using designated databases and verification resources.
- • Enter and maintain accurate data in credentialing software; track expirations and milestones.
- • Educate department coordinators and clinic staff on credentialing timelines, documentation, and best practices.
- • Evaluate provider qualifications against privileging criteria and payer enrollment requirements.
- • Coordinate pre-employment and onboarding requirements such as immunizations, BLS/ACLS, TB testing, and drug screening as needed.
- • Prepare complete credentialing files for committee review; present findings and make recommendations.
- • Advise leadership on process improvements to reduce time-to-credential and time-to-privilege.
- • Coordinate credentialing for locum tenens and temporary providers with staffing agencies and facilities.
- • Audit credentialing files for completeness, accuracy, and adherence to accreditation and payer standards; implement corrective actions.
- • Verify eligibility and maintain CAQH/PECOS profiles; submit and track payer enrollments, revalidations, and reattestations.
- • Respond to payer and facility requests for additional information and resolve enrollment or privileging holds.
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Tasks & skills:
O*NET occupational data (work activities, skills, knowledge).
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Last reviewed: Jan 2026
