Credentialing Coordinator

POSITION SUMMARY

Under the direct supervision of the Finance Director, the Credentialing Coordinator manages the verification, enrollment, and re-credentialing processes for healthcare providers at Charles Drew Health Center. The Credentialing Coordinator will be the subject matter expert of credentialing ensuring all healthcare providers hold valid licenses, certifications, malpractice insurance, and maintaining full compliance with state, federal, and organizational regulations.

POSITION COMPETENCIES/ESSENTIAL FUNCTIONS/DUTIES & RESPONSIBILITIES

• Handle initial credentialing, privileging, and re-credentialing packets for healthcare providers.
• Validate education, training, work history, board certifications, and active licenses.
• Monitor upcoming license and certification expiration dates to prevent compliance lapses.
• Prepare documentation files and assist with internal or external regulatory compliance audits.
• Coordinate with healthcare providers, insurance payers, and credentialing committee.
• Input and update provider profiles accurately within credentialing software and systems like CAQH and Maximus PDMS.
• Ensure compliance with state and federal statutory requirements including the Centers for Medicare and Medicaid Services (CMS), Nebraska Medicaid Program, and Nebraska Department of Health and Human Services (DHHS).
• Function as the primary staff liaison for credentialing healthcare providers.
• Manage and monitor the process for ensuring credentialing and enrollment of CDHC locations and providers to maximize third party insurer patient revenues, including Medicare, Medicaid and primary commercial plans.
• Lead, develop, and maintain procedures to monitor and review compliance with processes and procedures related to credentialing healthcare providers.   
• Participate in professional development activities, including keeping current with trends and best practices in health center operations, and personal leadership and management development.
• Provide leadership and management of special projects, as assigned.
• Provide secondary billing duties to include reviewing and submitting claims for processing, verifying insurance coverage, resolving denials, and responding to patient billing inquiries via phone and email.
• Other duties, as assigned.

Qualifications

POSITION REQUIREMENTS

• High School Diploma or equivalent required, Associate’s degree in Business Administration, Public Health, Public Administration, or related field, strongly preferred.
• At least 2 years of healthcare provider credentialing and billing experience.  
• Expertise of community based primary care models, more specifically Federally Qualified Health Centers preferred..
• Excellent track record of customer service and collaboration.
• Familiarity with medical terminology, accreditation standards (such as NCQA or The Joint Commission), and database software.
• Demonstrated mastery of critical thinking, analytics, problem solving and sound decision making skills required.
• Demonstrated ability to interact and communicate effectively with individuals at various levels both inside and outside of the organization, often in sensitive situations.
• Proficiency with Microsoft Office – particularly Excel, Word, and PowerPoint