Physician Credentialing Specialist

Job Description

A credentialing specialist plays a critical role in ensuring that healthcare providers meet all regulatory, payer, and organizational requirements. Key responsibilities include:

• Application Management

  • Prepare, collect, and submit credentialing and re-credentialing applications for physicians/

  • Maintain accurate provider files and track expirations for licenses, certifications, and malpractice coverage.

• Verification

  • Conduct primary source verification of education, training, board certifications, work history, and professional references.

  • Confirm active state licenses, DEA registrations, malpractice history, and sanctions/exclusions (e.g., OIG, NPDB checks).

• Compliance & Standards

  • Ensure adherence to federal, state, and payer regulations.

  • Maintain credentialing policies and procedures in line with accrediting body standards.

• Payer Enrollment

  • Submit and follow up on provider enrollment with Medicare, Medicaid, and commercial insurance networks.

  • Track effective dates and resolve delays to avoid reimbursement issues.

• Database & Records Management

  • Maintain credentialing databases (e.g., CAQH, Echo, MD-Staff).

  • Monitor expiring documents and send reminders to providers for renewals.

• Communication & Coordination

  • Serve as a liaison between providers, practice management, insurance companies, and regulatory bodies.

  • Provide updates to leadership on credentialing status and barriers.

• Auditing & Quality Assurance

  • Conduct internal audits to ensure credentialing files are complete and accurate.

  • Prepare reports for leadership, compliance, and accreditation surveys.

One of the Nations Leading Medical Groups specializing in the treatment of diseases affecting the retina, the vitreous and the macula using State of the Art Diagnostic Equipment and Facilities.

One of the Nations Leading Medical Groups specializing in the treatment of diseases affecting the retina, the vitreous and the macula using State of the Art Diagnostic Equipment and Facilities.