Credentialing Specialist

at Spectrum Healthcare Partners in South Portland, Maine, United States

Job Description


Ensure all regulatory elements of credentialing and privileging are in place and administers a standardized, consolidated system approach to support the clinical roles and settings for our clients across the U.S., including both single-specialty and multi-specialty physician healthcare organizations. . As a Medical Staff Professional, responsible for conducting, participating in, and maintaining: compliance with regulatory standards, clinical competency evaluations, maintaining compliance with regulatory standards, managing the credentialing/privileging process, performing primary source verification, and collaborating with other professionals to fulfill the core functions of the Medical Staff Services team. Utilizes specialized knowledge in the areas of medical staff services administration, accreditation compliance, credentialing processes, privileging, risk management, medical staff law, peer review, and information management to fulfill the requirements of this position. This position can be remote or on-site in South Portland, Maine ESSENTIAL FUNCTIONS

+ Works collaboratively within a cross-functional team of credentialing and enrollment professionals to provide full-service solutions to providers and at various client organizations

+ Facilitates initial appointment and reappointment credentialing for clinical providers including but not limited to: physicians and various mid-level providers across multiple healthcare facility sites of service

+ Self-directs the preparation and submission of applications on behalf of new and existing providers in a time-sensitive manner

+ Gathers compiles, analyzes, and evaluates provider-specific information based on the requirements of each healthcare facility with strict attention to accreditation standards

+ Obtains primary and secondary source verifications in accordance with accreditation standards and internal policies; verification requirements may include provider education, training, license history, malpractice history, databank history, hospital affiliation history, CME, OIG, and peer references

+ Critically analyzes data to create informed recommendations for credentialing, reappointment, and privileging proceedings in conjunction with Medical Directors

+ Works with hospitals to ensure providers are credentialed and granted privileges

+ Conducts, participates in, and maintains development and enforcement of medical staff bylaws, rules and regulations, and policies that govern the activities of the medical staff for the Company

+ Researches and develops credentialing/privileging requirements for new types of practitioners, new service-line development, or different specialties

+ Consults on and recommends privilege criteria to provide better oversight and demonstrate meaningful provider quality

+ Maintains all practitioner files to ensure compliance with AAAHC standards

+ Serves as an expert for AAAHC, JHACO, or other regulatory agencies for surgical centers, when applicable

+ Works collaboratively with internal and external Quality Departments to establish and maintain workflows for privileging, OPPE/FPPE reporting, and other practitioner-based requirements

+ Reviews provider information for accuracy and completeness and follow-ups with providers to obtain missing information

+ Works collaboratively with int ernal and external Risk Management teams in meeting Board of Licensure or facility reporting requirements.


+ Participates in process improvement activities

+ Documents work assignments within the specified systems and timeframes

+ Maintains good working relationships and open communication channels with internal and external customers including providers, specialty practices, leadership, healthcare facilities, state and federal agencies

+ Documents provider data and application tracking as part of a comprehensive credentialing database; follows established data entry protocols of the department

+ Identifies and resolves system issues independently or with assistance from the IT department

+ Maintains a large library of required credentialing forms, applications, and releases

+ Organizes and prioritizes workload and facilitates multiple projects within assigned deadlines

+ Maintains personal adherence to professional and confidentiality standards established within the department and in accordance with legal, ethical and internal policies

+ Performs other credentialing, privileging, and licensing duties as assigned, including payor enrollment, maintenance of Certification tracking, CAQH re-attestations, and off-boarding

+ Attends meetings as assigned and participates in educational activities to keep skills up to date

+ Demonstrates professionalism at all times

+ Displays cooperative behavior and interacts positively and effectively with others to promote a team environment

+ Performs other duties necessary to maintain the overall efficiency and continuity of the department

+ Is proactive in identifying, reporting, and participating in the resolution of any potential or safety issues


+ College degree or equivalent combination of relevant experience in a healthcare setting

+ 3-5 years’ related job experience in credentialing and privileging or physician-related field required; experience with Radiology practices strongly preferred

+ Professional certification through the National Association of Medical Staff Services as Certified Provider Credentialing Specialist (CPCS) desired

+ Working knowledge of Joint Commission and other regulatory standards, guidelines and regulations desired

+ Articulates and demonstrates commitment to the philosophy, value, mission, and vision of the Company

+ Highly proficient in current Microsoft Windows environment, relational databases, spreadsheets, word processing, electronic documents, and e-mail systems required

+ Excellent organizational, time management skills with attention to detail

+ Excellent communication and interpersonal skills with the ability to professionally communicate with physicians, leadership, and all levels of staff

+ Ability to work independently and as a member of a team

+ Excellent customer service skills

+ Ability to maintain confidentiality


+ Operation of various office equipment; fax machine, telephone & voice mail system, stationary/laptop computer, dictation machine, scanner, e-mail system, cell phone, pager, and copier

+ Requires prolonged sitting, keyboarding, and repetitive reaching

+ Light lifting of paperwork, folders, or other general record-keeping materials

+ Occasional travel to various locations for meetings or professional development events ???


+ Health insurance (80% company-paid)

+ Dental & Vision Insurance Plans

+ 401(k) Match and Profit-Sharing Plans

+ Life and Accidental Death and Dismemberment Insurance

+ Long-term Disability Insurance

+ Short-term Disability Insurance

+ Short-term Disability Insurance

+ Generous Paid Time Off

+ Voluntary, Employee-Paid Benefits

+ Medical Reimbursement Plan

+ Dependent Care Plan

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Job Posting: JC192789798

Posted On: Sep 19, 2021

Updated On: Oct 19, 2021