Quick overview
Job description
Sr Credentialing Specialist, PBO Credentialing, Full Time
This is a multi-faceted position encompassing elements of administrative tasks, customer service, and credentialing verifications. Prepares, documents, and completes credentialing data processes including applications and verifications for Medical and Allied Health staff. Performs administrative tasks, such as compiling data from providers, preparing applications, maintaining clean and organized files, and maintaining current documents and enrollments for providers.
Advanced Credentialing and Complex Case Management:
Independently manages complex credentialing and enrollment applications from receipt through completion across multiple payors, provider types, and jurisdictions.
Analyzes nonstandard requirements, resolves complex documentation or system discrepancies, and coordinates corrective action with providers, internal departments, payors, and external entities.
Completes and validates CAQH, Cactus, paper and electronic applications, spreadsheets, and payor portal records for accuracy, completeness, and compliance.
Manages high-risk or time-sensitive cases, establishes follow-up plans, and communicates material barriers and resolution status to leadership.
Advanced Enrollment and Regulatory Maintenance:
Independently manages complex provider terminations, practice location changes, participation records, taxonomy, specialty, demographics, licensure, DEA, malpractice, and related updates across payors and systems.
Coordinates complex hospital affiliation and privileging activities, including appointments, reappointments, and required maintenance documentation.
Completes and resolves complex state-specific Medicare and Medicaid maintenance, revalidations, recertifications, and related regulatory updates.
Identifies cross-system or multi-payor inconsistencies, determines corrective action, and ensures supporting records are complete and audit-ready.
Quality Review and Audit Support:
Reviews credentialing and enrollment maintenance work for accuracy, completeness, timeliness, and adherence to payor, regulatory, and departmental requirements.
Identifies recurring defects, documents findings, supports audit requests, and recommends corrective training or controls to reduce recurrence.
Escalation Management and Advanced Issue Resolution:
Serves as an escalation resource for complex participation, location, affiliation, regulatory, and enrollment maintenance issues.
Investigates root causes, coordinates resolution across stakeholders, and recommends action when requirements conflict or established procedures do not address the issue.
Process Improvement and Special Projects:
Leads or supports workflow improvement, data integrity, system cleanup, implementation, and other high-impact departmental projects.
Evaluates process gaps, recommends standardized controls and documentation updates, and monitors whether changes produce the intended result.
Mentoring and Subject Matter Expertise:
Provides technical guidance, coaching, and workflow support to credentialing staff while reinforcing established procedures and quality expectations.
Serves as a subject matter resource for assigned payors, systems, regulatory programs, or maintenance functions and assists leadership with knowledge transfer and cross-training.
Customer Service:
Provides authoritative, timely, and accurate support to providers, payors, internal departments, and external partners on complex credentialing and enrollment matters.
Communicates risks, requirements, decisions, and resolution steps clearly to support timely completion and prevent repeat issues.
File Maintenance and Department Support:
Maintains complete, accurate, confidential, and audit-ready records for assigned work and advanced case activity.
Provides operational coverage and performs other duties consistent with the senior scope of the position.
- Minimum Required: High school diploma or GED.
- Preferred: Associate degree in healthcare administration, business administration, health information management, or related field.
- CPCS (Certified Provider Credentialing Specialist) preferred.
- Eight or more years of progressively responsible credentialing, provider enrollment, or enrollment maintenance experience in a hospital, physician office, health system, or managed care setting required.
- Experience handling complex cases, escalations, quality review, regulatory maintenance, or staff guidance preferred.
At UC Health, we're proud to have the best and brightest teams and clinicians collaborating toward our common purpose: to advance healing and reduce suffering.
As the region's adult academic health system, we strive for innovation and provide world-class care for not only our community, but patients from all over the world. Join our team and you'll be able to develop your skills, grow your career, build relationships with your peers and patients, and help us be a source of hope for our friends and neighbors.
UC Health is an EEO employer.