Credentialing Coordinator (55435)

Position summary

Coordinates internal credentialing and privileging and external payer enrollment for behavioral health providers, programs, and facilities. Collects and verifies documentation, prepares committee materials, tracks approvals and renewals, and maintains accurate provider records. Partners with HR, clinical leadership, billing, and payers to support timely onboarding and accurate communication of provider service and billing status.

Essential functions:

Internal credentialing and privileging

• Coordinate initial credentialing and recredentialing for applicable employees and contracted providers according to agency procedures.
• Obtain and review applications, education records, licenses, certifications, work history, and other required supporting documents; complete primary source verification and required screening checks within assigned responsibilities.
• Prepare Staff Supplementary Forms, Credentialing Requirements forms, QMHP packets, and supporting materials for Credentialing Committee review.
• Assist with committee meetings, track outstanding items, document decisions, and issue approval notices following authorized committee action.
• Coordinate confirmation of approved provider types, service privileges, and required clinical or billing supervisors with clinical leadership and billing; refer eligibility questions or adverse findings to the appropriate decision maker.
• Maintain confidential credentialing files and track changes in licensure, credentials, supervision, or employment status.

External credentialing and payer enrollment

• Prepare and submit provider, program, and facility applications for credentialing, recredentialing, enrollment, and revalidation with Medicaid, Medicare, MCOs, and commercial payers.
• Follow up on submissions, resolve missing documentation, and track payer decisions, effective dates, and outstanding requirements.

External credentialing and payer enrollment continued

• Create and maintain provider profiles in CAQH and applicable enrollment portals; coordinate required attestations and updates with providers.
• Submit approved demographic, location, licensure, insurance coverage, and provider affiliation changes to applicable payers and oversight entities.
• Coordinate applications and renewals for agency and facility licenses and submit supporting records, including certificates of insurance, as required.
• Maintain provider billing status reports and communicate confirmed payer approvals and effective dates to HR, clinical leaders, and billing staff.
• Coordinate enrollment changes and payer notifications when providers transfer or leave the agency; retain documentation of completed actions.
• Maintain authorized access to payer portals according to agency security procedures and each portal’s current requirements.
• Serve as a liaison among providers, HR, clinical leadership, billing, credentialing committee members, payers, and external agencies.

Job Requirements/Expectations

• Protect confidential provider, employee, and client information; follow agency policies and applicable privacy and security requirements.
• Complete assigned training, participate in meetings, and contribute to department goals and continuous improvement.
• Provide clear, respectful communication and timely follow up; promptly escalate concerns that may affect service authorization or billing.
• Ability to collect, verify, organize, and maintain accurate documentation with strong attention to detail and confidentiality.
• Working knowledge of provider credentialing, payer enrollment, licensure verification, and the distinction between internal privileges and external payer approval.
• Ability to track multiple applications and deadlines, research requirements, identify discrepancies, and follow through on unresolved items.
• Proficiency with Microsoft 365, especially Excel, Word, and Outlook; ability to learn credentialing databases, payer portals, and electronic health record systems.
• Strong written and verbal communication, customer service, problem solving, and collaborative working skills.
• Ability to work independently within established procedures and recognize when an issue requires leadership, committee, clinical, or billing review.

Qualifications

Work environment and physical demands

Primarily an office setting with extended computer work and periods of sitting, with occasional standing and walking. Duties involve keyboard use, reviewing electronic and printed records, communicating with staff and external contacts, and occasionally moving office materials weighing up to 10 pounds. Reasonable accommodations may be provided to enable qualified individuals to perform essential functions.

Education and experience

Proposed minimum: Associate’s degree in healthcare administration, health information management, business, or a related field and at least two years of relevant healthcare administrative or credentialing experience; or a high school diploma or equivalent and at least four years of relevant experience.

Preferred: Bachelor’s degree in a related field; experience in behavioral health credentialing, Kentucky Medicaid, payer enrollment, or provider privileging; Certified Provider Credentialing Specialist certification.

All employees must be willing to live our company's core values.

• Integrity – Exhibiting the highest moral, ethical and legal standards. Doing the right thing – even when no one else is looking. 
• Teamwork – Putting team success over personal success. Actively valuing the strengths and talents of others. 
• Trust/Respect– Seeing and believing in the good intentions of others. Interacting with others in a way that makes them feel valued. Listening without judging. Offering understanding and acceptance.
• Care/Compassion – Demonstrating unconditional kindness, concern and empathy. Exhibiting genuine concern for others.
• Ownership/Accountability – Taking personal responsibility for one’s work, actions and feelings. Accepting responsibility for and learning from mistakes.