Credentialing and Licensing Specialist III

Job Description Summary

The Credentialing and Licensing Specialist III performs advanced-level credentialing and licensing work for healthcare providers to ensure compliance with regulatory accreditation payer and organizational requirements. Reviews validates tracks and maintains provider credentialing documentation licensure records certifications enrollment information and related provider data. Coordinates with providers internal stakeholders licensing boards payers and external agencies to resolve credentialing and licensing matters and support timely credentialing recredentialing enrollment and renewal activities.

How will you make an impact & Requirements

Key Responsibilities

• Process provider credentialing recredentialing licensing enrollment and renewal activities.
• Review and validate credentialing documentation including licenses certifications education training malpractice coverage work history sanctions exclusions and other required provider information.
• Research and resolve non-routine credentialing licensing payer enrollment or provider data discrepancies escalating complex compliance or regulatory concerns when needed.
• Monitor expiration dates application status missing documentation and renewal timelines to support timely provider participation and compliance.
• Maintain provider records and credentialing databases with a high degree of accuracy completeness and data integrity.
• Communicate with providers licensing boards payers credentialing committees regulatory agencies and internal stakeholders regarding requirements status updates and issue resolution.
• Support audits accreditation reviews compliance reporting and credentialing committee preparation by gathering documentation validating records and responding to information requests.
• Provide informal training guidance or quality review support to less experienced credentialing staff on systems procedures and documentation standards as needed.

Qualifications

• High school diploma required; associate degree preferred.
• 35 years of credentialing licensing provider enrollment healthcare administration or related experience.
• In-depth knowledge of provider credentialing recredentialing licensing payer enrollment and provider data management processes.
• Working knowledge of applicable regulatory accreditation payer and organizational credentialing requirements; familiarity with NCQA CMS state licensing or related standards preferred.
• Experience using credentialing software provider databases payer portals or HRIS/provider data systems preferred.
• Strong attention to detail follow-through organization and ability to manage multiple deadlines and documentation requirements.
• Ability to resolve non-routine issues interpret established procedures and communicate effectively with providers payers agencies and internal stakeholders.
• CPMSM CPCS or equivalent certification preferred but not required.