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Credentialing Specialist
Astrana Health. Review, prepare, and submit provider credentialing, enrollment, and recredentialing applications for health plans, government programs, and healthcare organizations .
Core Competencies
Role fitCore Competencies
Use this summary to align your resume positioning with the role.
Demonstrates expertise in provider credentialing processes, including enrollment and compliance with healthcare regulations. Proficient in managing sensitive information and maintaining accurate records while ensuring timely completion of credentialing tasks.
Highest-signal resume keywords
Provider Credentialing ExperienceCAQH ManagementMedicare EnrollmentCredentialing Certification (CPCS or CPMSM)Healthcare Regulatory Compliance
ATS Keywords
Tailor your resumeApplicant Tracking System Keywords
Tip: use these terms in your resume and cover letter to boost ATS matches.
Hard Skills
Provider EnrollmentCredentialing StandardsEnrollment ProceduresElectronic Health RecordsCredentialing SoftwareData ManagementAnalytical SkillsAttention to DetailProblem-SolvingTime Management
Soft Skills
Organizational SkillsCommunication Skills
Tools & Technologies
Microsoft Office SuiteAthenahealthPractice Management SystemsCredentialing Platforms
Certifications & Qualifications
CPCS (Certified Provider Credentialing Specialist)CPMSM (Certified Professional Medical Services Management)
Industry Keywords
Managed CareHealth PlanIPAMSOFQHCNCQAOIGSAMMedicaidMedicare
About the role
Key responsibilities & impact- Review, prepare, and submit provider credentialing, enrollment, and recredentialing applications for health plans, government programs, and healthcare organizations
- Manage provider enrollment and maintenance activities within CAQH, PECOS, NPPES, Medicare, Medicaid, and commercial payer portals
- Verify provider qualifications, including education, licensure, certifications, malpractice coverage, and other required documentation
- Maintain accurate credentialing records and monitor renewal timelines to ensure compliance and uninterrupted participation
- Ensure compliance with CMS, Medicare, Medicaid, NCQA, state, and health plan credentialing requirements
- Conduct ongoing exclusion monitoring, including OIG, SAM, and state exclusion screenings
- Research, resolve, and escalate credentialing issues, discrepancies, and payer-related concerns
- Assist with credentialing audits, provider inquiries, and health plan requests
- Partner with providers and internal departments to maintain accurate provider data and timely credentialing completion
- Prepare and provide credentialing status reports and updates to leadership
Requirements
What you’ll need- High school diploma or equivalent required
- At least 2 years of provider credentialing experience within a physician practice, medical group, IPA, MSO, health plan, or managed care environment
- Experience with CAQH, PECOS, NPPES, Medicare enrollment and revalidation, Medicaid enrollment, and commercial payer credentialing processes
- Strong knowledge of credentialing standards, enrollment procedures, and healthcare regulatory requirements
- Experience working with electronic health records, practice management systems, and credentialing platforms
- Proficiency with Microsoft Office Suite, including Word, Excel, and Outlook
- Strong analytical, organizational, communication, problem-solving, and time management skills
- Exceptional attention to detail and ability to manage sensitive and confidential information
- Credentialing certification through NAMSS, including CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management) preferred
- Experience using credentialing software and provider enrollment databases preferred
- Experience with Athenahealth preferred
- Experience within a managed care, IPA, MSO, FQHC, medical group, or health plan environment preferred
- Familiarity with provider network management and healthcare technology systems preferred
Benefits
Comp & perks- This role follows a remote work structure with periodic travel required to our clinics.
- Must be able to work at a computer for extended periods, review electronic medical records and coding reports, and communicate effectively with providers and staff via phone, video conferencing, email, and Teams chat.
- Ability to attend provider meetings, trainings, and market events as needed.