Credentialing Professional

The Credentialing Professional is responsible for gathering and reviewing provider documentation to determine credentialing and health plan eligibility. This role handles a variety of work assignments that often require independent judgment, problem-solving, and interpretation of guidelines to determine next steps. The Credentialing Professional 2 works with minimal supervision and supports timely, accurate credentialing to ensure providers meet organizational and regulatory requirements.

The Credentialing Professional reviews the applicant's education, training, clinical privileges, experience, licensure, accreditation, certifications, professional liability insurance, malpractice history and professional competence. Reviews the information and documentation collected, as well as verification that the information is accurate and complete. Understands department, segment, and organizational strategy and operating objectives, including their linkages to related areas. Makes decisions regarding own work methods, occasionally in ambiguous situations, and requires minimal direction and receives guidance where needed. Follows established guidelines/procedures.

Required Qualifications

• Associate's degree or related experience
• A minimum of three years of credentialing experience in healthcare
• Prior work experience in an auditing function
• Ability to prioritize workload to ensure deadlines are met
• Excellent written and oral communication skills required.
• Excellent PC skills (including MS Word, Excel and Access) required.
• Must be passionate about contributing to an organization focused on continuously improving consumer experiences
• Medicare and Medicaid Knowledge
• Familiar with CAQH

Preferred Qualifications

• Bachelor's degree in Business, Health Administration, Accounting or related field required.
• Bilingual; English & Spanish
• Experience in managed care or health care administration desired.

Additional Information

• Remote Role
• Preferred location: Florida
• Standard working hours required; 8:00 am - 5:00 pm; Eastern Time Zones

Work at Home Statement

To ensure Home or Hybrid Home/Office employees' ability to work effectively, the self-provided internet service of Home or Hybrid Home/Office employees must meet the following criteria:

• At minimum, a download speed of 25 Mbps and an upload speed of 10 Mbps is required; wireless, wired cable or DSL connection is suggested.
• Satellite, cellular and microwave connection can be used only if approved by leadership.
• Employees who live and work from Home in the state of California, Illinois, Montana, or South Dakota will be provided a bi-weekly