Credentialing Specialist

Position Summary

The Speech/OT/PT/BCBA Credentialing Specialist is responsible for managing all provider credentialing re-credentialing and attestation activities to ensure compliance with regulatory payer county-specific CMH entities and organizational requirements. This role supports the full credentialing lifecycle including application management payer enrollments CAQH profiles primary source verification ongoing monitoring and documentation accuracy.

In addition to credentialing responsibilities this position provides administrative support to the Human Resources department assisting with record maintenance employee file management ongoing compliance and general HR operations.

Essential Duties & Responsibilities

Credentialing & Compliance

Manage the full-cycle credentialing recredentialing and CAQH attestation process for all clinical providers including Physical Therapists Occupational Therapists Speech-Language Pathologists Board Certified Behavior Analysts Registered Behavior Technicians Social Workers and other licensed professionals.

Complete and submit credentialing and enrollment applications for both commercial/private insurance payers and county-specific Community Mental Health (CMH) entities.

Maintain accurate audit-ready credentialing records and tracking systems for all applications deadlines and payer requirements.

• Monitor expirations for licenses certifications malpractice insurance and other required documents; send reminders and ensure timely renewals.

Review provider documentation (licenses certifications malpractice coverage NPI CAQH education/experience records) for completeness and accuracy prior to submission.

Ensure CAQH profiles are kept current including timely attestations and document updates for all providers.

Serve as the primary point of contact between the organization and insurance payers/CMH entities to address application questions missing information or follow-up requests.

Maintain up-to-date knowledge of payer-specific credentialing criteria enrollment processes contractual requirements and policy changes that may impact provider status or reimbursement.

Verify provider credentials during onboarding and ensure all necessary documents and data are collected before initiating the credentialing process.

• Conduct primary source verifications in accordance with federal state payer and accreditation requirements.

Communicate credentialing status updates and expected timelines to internal stakeholders including HR Billing Finance and Clinical Leadership.

Track and manage payer recredentialing cycles to ensure continuous provider participation without lapses in authorization or reimbursement.

Troubleshoot and resolve credentialing or enrollment issues that may impact claims processing provider participation or revenue cycle operations.

Support contract negotiation or amendment processes by providing credentialing-related data and coordinating payer documentation as needed.

Participate in internal audits compliance reviews and quality improvement initiatives related to credentialing operations.

HR Administrative Support

• Support onboarding processes including collecting documentation preparing new hire files and assisting with system setup.
• Maintain accurate employee records digital files and HR documentation in accordance with company policy county-specific compliance standards and retention requirements.
• Assist in scheduling meetings training and compliance-related activities.
• Provide general HR administrative support such as data entry correspondence scanning and filing.
• Support HR projects compliance initiatives and process improvements as needed.

Required Qualifications

• Associates degree required coursework or a bachelors degree in HR Healthcare Administration or a related field preferred
• Certified Provider Credentialing Specialist (CPCS) or Provider Enrollment Specialist Certificate (PESC) preferred
• 2 years of experience in medical credentialing provider enrollment or a healthcare compliance role.
• Experience working in an HR or administrative support capacity preferred.
• Strong understanding of credentialing requirements CAQH management NPI registry processes and payer enrollment workflows.
• Must possess exceptionally strong organizational skills with the ability to manage detailed credentialing workflows track multiple deadlines and maintain accurate up-to-date documentation in a fast-paced environment.
• Demonstrated ability to work independently solve problems proactively and follow complex multi-step processes.

Skills & Competencies

• Excellent attention to detail and accuracy.
• Strong organizational and time-management abilities.
• Ability to handle sensitive information with confidentiality.
• Proficiency in Microsoft Office and HRIS/credentialing software systems.
• Effective written and verbal communication skills.
• Ability to prioritize and manage multiple tasks in a deadline-driven environment.

Working Conditions

• Office environment.
• Regular use of computer systems databases and digital communication tools.
• May require occasional overtime as needed which includes but not limited to: during peak credentialing recredentialing attestation and onboarding periods.