Job Description

Job Description

Job Description

Job Overview

The Medical Credentialing Specialist is responsible for managing the full life-cycle credentialing and re-credentialing process for physicians and allied health professionals. You will gather, verify, and maintain provider information; interface with insurance payers and regulatory bodies; and ensure that all practitioners meet the organization’s, payer’s, and governmental compliance standards so they can bill and be reimbursed promptly.

Main Responsibilities:

Provider On-Boarding & Re-Credentialing * Collect and verify licensure, certifications, malpractice coverage, sanctions history, and education/training. * Submit complete applications to Medicare, Medicaid, and commercial payers; monitor status until approval. * Track expirations and initiate re-credentialing well in advance of deadlines.

Primary Source Verification: Perform primary source checks (NPDB, OIG, SAM, FSMB, DEA, state boards). * Document all verification steps to meet NCQA, URAC, and Joint Commission standards.

Payer & Regulatory Coordination: Serve as main liaison between the organization, providers, and insurance networks. * Resolve discrepancies or requests for additional information quickly.

Database & Record Management: Maintain accurate provider data in credentialing software (e.g., CAQH, PECOS, Modio, Verity). * Generate routine and ad-hoc credentialing status reports for leadership.

Compliance & Policy Development: Keep current with federal/state regulations and payer rules; recommend policy updates. * Participate in internal audits and quality-improvement projects.

Customer Service & Communication: Educate providers on credentialing requirements and timelines. * Communicate professionally with payers, clinics, and management to minimize enrollment delays.

Required Qualifications:

• Education: High-school diploma or GED (required); Associate’s or Bachelor’s degree in healthcare administration, business, or a related field (preferred).

• Experience: 2 + years in medical staff credentialing, payer enrollment, or provider relations within a hospital, medical practice, or centralized credentialing office.

• Technical Skills:

  • Proficiency with credentialing/enrollment software (e.g., CAQH ProView, PECOS, Availity).

  • Solid grasp of Microsoft Office or Google Workspace, especially Excel/Sheets for tracking.

• Knowledge Base: Working knowledge of CMS guidelines, commercial payer requirements, NCQA and/or URAC standards, and HIPAA privacy rules.

• Certifications (preferred): Certified Provider Credentialing Specialist (CPCS) or Certified Professional Credentialing and Privileging Specialist (CPCPS).

Core Competencies:

• Detail Orientation: Meticulous record-keeping and error-free application preparation.

• Time Management: Ability to juggle multiple providers, payers, and deadlines simultaneously.

• Critical Thinking & Problem-Solving: Identify credentialing obstacles early and devise solutions.

• Communication: Clear, concise written and verbal skills for interacting with providers and insurers.

• Confidentiality & Ethics: Handle sensitive provider data in full compliance with privacy laws.

Preferred Traits:

• Familiarity with delegated credentialing contracts.

• Experience supporting multispecialty or multi-state groups.

• Solid understanding of revenue-cycle implications of enrollment delays.

Work Environment & Schedule:

• Setting: Office-based or hybrid depending on organization approval; frequent computer and phone use.

• Hours: Monday–Friday, standard business hours, with occasional overtime to meet deadlines.

• Reports To: Credentialing Manager, Revenue Cycle Director, or Medical Staff Services Manager.

Performance Metrics:

• Average days from provider hire to payer approval

• Percentage of applications accepted on first submission

• Timeliness of re-credentialing (before expiration)

• Compliance audit scores (NCQA/URAC/Joint Commission)

Johnson Consulting LLC is a health care based consulting firm specializing in managing multiple different types of medical specialities for private practices. We currently consult for multiple firms, with the number of locations coming in at almost 50 across 4 different states. We are continuously growing and have recently been rated by Healthcare Business Review as one of the top ten medical practice management firms in the country. We offer a number of different services that our client utilize for their own private practice, including the following: access to capital, project management, practice management, operations expertise, long-term strategy and implementation, ancillary service management, outsourced CFO work, vendor management, and consulting. We have a team of highly experienced business and medical professionals who have been in their respective fields for years. This is why we have recently been named one of the top ten management firms in the country and we are continously growing every single year!

Company Description

Johnson Consulting LLC is a health care based consulting firm specializing in managing multiple different types of medical specialities for private practices. We currently consult for multiple firms, with the number of locations coming in at almost 50 across 4 different states. We are continuously growing and have recently been rated by Healthcare Business Review as one of the top ten medical practice management firms in the country. We offer a number of different services that our client utilize for their own private practice, including the following: access to capital, project management, practice management, operations expertise, long-term strategy and implementation, ancillary service management, outsourced CFO work, vendor management, and consulting. We have a team of highly experienced business and medical professionals who have been in their respective fields for years. This is why we have recently been named one of the top ten management firms in the country and we are continously growing every single year!

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