Summary: The Credentialing Specialist is responsible for coordinating, processing, and maintaining all physician and provider credentialing, recredentialing, privileging, and enrollment activities for the orthopaedic practice. This position ensures providers meet all regulatory, accreditation, payer, and facility requirements necessary to provide patient care and receive reimbursement for services rendered.

The Credentialing Specialist works closely with providers, management, hospitals, insurance payers, and regulatory agencies to maintain accurate and timely credentialing records.

General Summary of Duties: (Other duties may be assigned.)

Coordinate and manage provider credentialing and recredentialing processes for physicians, physician assistants, nurse practitioners, therapists, and other clinical staff.

Prepare and submit credentialing applications to commercial insurance carriers, Medicare, Medicaid, hospitals, surgery centers, and other healthcare organizations.

Maintain accurate provider files, credentialing databases, and tracking systems.

Monitor expiration dates for licenses, DEA registrations, board certifications, malpractice insurance, ACLS, CPR certifications, and other required credentials.

Ensure timely completion of payer enrollment and revalidation applications.

Follow up with insurance carriers and facilities regarding application status and approvals.

Maintain CAQH profiles and ensure all provider information is current and attested as required.

Assist with provider privileging and hospital appointment processes.

Verify provider credentials including education, training, licensure, certifications, malpractice coverage, and work history.

Ensure compliance with federal, state, payer, and accreditation standards.

Communicate with providers regarding missing documentation and renewal requirements.

Maintain confidentiality of provider and organizational information.

Assist with audits, reports, and credentialing documentation requests.

Collaborate with billing, compliance, human resources, and administrative staff regarding provider enrollment and credentialing matters.

Perform other duties as assigned.

Qualifications: To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill and/or ability required.

Education and Training:

High School diploma or equivalent required at minimum

Experience in physician practice credentialing, within an orthopaedic or specialty medical practice, preferred.

Knowledge of Medicare, Medicaid, and commercial payer enrollment processes preferred.

Knowledge of healthcare regulations, payer requirements, and credentialing standards.

Excellent organizational skills and attention to detail.

Ability to manage multiple deadlines and prioritize tasks effectively.

Strong written and verbal communication skills.

Proficient in Microsoft Office applications and credentialing software/databases.

Ability to maintain confidentiality and handle sensitive information appropriately.

Physical Demands and Working Conditions/Requirements:

Requires prolonged periods of sitting at desk, working at computer, and being on the phone

Must have good computer and telephone communication skills and able to operate miscellaneous office equipment

Hearing and vision abilities within normal range, or corrected, to observe and communicate with patients and staff

Ability to work in fast-paced environment in a professional medical office setting

Reasonable accommodations may

Orthopaedic Institute of Ohio

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Credentialing Specialist