About this role
Company Conformance Statements
In the performance of their respective tasks and duties all employees are expected to conform to the following:
- Perform quality work within deadlines with or without direct supervision.
- Interact professionally with other employees, customers and suppliers.
- Work effectively as a team contributor on all assignments.
- Work independently while understanding the necessity for communicating and coordinating work efforts with other employees and organizations.
Position purpose:
Reporting to the VP of Clinical Integrations & Shared Services, the Credentialing Specialist is responsible for managing all aspects of provider credentialing, recredentialing, payer enrollment, and privileging within an assigned region. This role partners closely with operational leaders to ensure proactive communication regarding credentialing requirements, enrollment timeframes, and provider onboarding activities. The Credentialing Specialist helps ensure timely provider activation and uninterrupted participation with contracted health plans.
Essential Duties and Responsibilities:
The essential functions include, but are not limited to, the following:
- Manage all aspects of provider credentialing, recredentialing, payer enrollment, and privileging activities for assigned providers and regions.
- Coordinate enrollment and credentialing processes with contracted commercial, government, and managed care payers.
- Ensure compliance with all payers, regulatory, accreditation, and organizational credentialing requirements.
- Participate in regular meetings with assigned regional leaders to review onboarding status, pending applications, and enrollment needs.
- Compile, maintain, and audit provider credentialing files to ensure all records are complete, accurate, and current.
- Prepare, submit, and monitor credentialing, recredentialing, and payer enrollment applications through completion and approval.
- Maintain current copies of provider licenses, DEA registrations, board certifications, malpractice insurance certificates, and other required credentials.
- Track expiration dates for licenses, certifications, registrations, and other credentials to ensure timely renewals and uninterrupted payer participation.
- Maintain accurate provider information within credentialing software (Modio), CAQH, PECOS, payer portals, and other applicable databases.
- Audit payer directories and provider listings to ensure provider information is accurate and up to date.
- Process provider demographic updates, including practice locations, billing information and other required updates.
- Identify opportunities to improve credentialing workflows and implement standardized best practices.
- Participate in quality improvement initiatives related to credentialing operations, payer enrollment, and data integrity.
- Maintain strict confidentiality of provider, patient, and organizational information.
- Perform additional duties and special projects as assigned.
Qualifications
Qualifications:
Education
- High school diploma or equivalent required.
- Associate or bachelors degree preferred.
Experience
- Minimum of three (3) years of experience in provider credentialing, payer enrollment, medical staff services, or related healthcare administration required.
- Strong knowledge of California Payers.
- Experience supporting multi-site physician practices or healthcare organizations preferred.
Preferred Knowledge, Skills, and Abilities
- Strong knowledge of provider credentialing, recredentialing, and payer enrollment processes.
- Working knowledge of commercial, Medicare, Medicaid, and managed care payer requirements.
- Experience utilizing CAQH, PECOS, Modio, and payer portals.
- Familiarity with credentialing standards established by NCQA, CMS, and other regulatory agencies.
- Excellent organizational and project management skills with the ability to manage multiple priorities and deadlines.
- Strong attention to detail and commitment to data accuracy.
- Excellent verbal and written communication skills.
- Strong problem-solving and analytical abilities, including the capacity to independently research and resolve issues.
- Proficient in Microsoft Office Suite, including Excel, Word, Outlook, and Teams.
- Ability to work collaboratively across departments while maintaining a high level of customer service.
- Ability to handle confidential information with discretion and professionalism.
Our competitive benefits package includes the following:
- Medical, Dental, and Vision insurance
- Short-term/Long-term disability
- Life and other voluntary plans
- 401(k) plan
- Employee Referral Program
- Paid Time-Off
- Company-Paid Holiday
Equipment Operated: Standard office equipment including computers, fax machines, copiers, printers, telephones, etc.
Physical Requirements: Must possess manual dexterity to operate office machines including computers and calculator; stooping and bending to handle files and supplies; and mobility to complete errands or deliveries. Includes handling of sharps and chemicals. Multiple staff demands and deadlines can trigger stress.
Equal Employment Opportunity:
Platinum Dermatology Partners is committed to a policy of equal employment opportunities for applicants and Employees. Employment decisions will comply with all applicable laws prohibiting discrimination in employment, including Title VII of the Civil Rights Act of 1964, The Age Discrimination in Employment Act of 1967, the Americans with Disabilities Act of 1990, the Immigration and Nationality Act, the California Fair Employment and Housing Act, and all other applicable state and federal laws.
Platinum Dermatology Partners does not permit discrimination of any type against an employee because of any of the following legally protected characteristics: gender, race, color, religion, country of origin, mental disability, physical disability, marital status, gender identity, gender expression, ancestry, genetic information, medical condition, age, sexual orientation, or pregnancy.
Please note that any offer of employment is contingent on the successful completion of pre-employment background checks.
No phone calls or agencies, please.