Credentialing Specialist

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  "last_changed_at": "2026-06-06T09:50:03.357Z",
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  "detail": {
    "city": "Tahlequah",
    "jobId": 39581,
    "level": "",
    "endDate": "",
    "legalId": 326,
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    "jobShift": "Day",
    "jobTitle": "Credentialing Specialist",
    "location": "Tulsa - Tulsa, OK 74146",
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    "description": "<p><span style=\"font-size:11pt;\"><span style=\"line-height:107%;\"><span style=\"font-family:Calibri, sans-serif;\"><b><span style=\"font-size:12pt;\"><span style=\"line-height:107%;\">Job Summary:</span></span></b></span></span></span></p>\r\n\r\n<p><span style=\"font-size:11pt;\"><span style=\"line-height:107%;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\"><span style=\"line-height:107%;\">The Credentialing Specialist is responsible for ensuring that the facilities in which they work and represent are always fully compliant with all state and federal regulations. They must also ensure that every staff member is legally licensed and/or has obtained all CEU&rsquo;s to obtain licensure renewal on time and is up-to-date with the latest medical policies and procedures. The Credentialing Specialist is accountable for the enrollment of providers in government and managed care health plans and communicating the status to internal staff. The incumbent is also responsible for managing relationships with contracted payers to help them understand administrative processes, medical policies, and reimbursement.</span></span></span></span></span></p>\r\n\r\n<p><span style=\"font-size:11pt;\"><span style=\"line-height:107%;\"><span style=\"font-family:Calibri, sans-serif;\"><b><span style=\"font-size:12pt;\"><span style=\"line-height:107%;\">Job Duties:</span></span></b></span></span></span></p>\r\n\r\n<ul>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Complete, monitor, and follow-up on provider Medicaid and commercial insurance credentialing and re-validation applications.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Monitor applications and follow-up as needed.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Maintain up-to-date data for each provider in credentialing databases and online systems.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Track license and certification expirations for all providers to ensure timely renewals.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Facilitate and ensure resolution of network provider issues related to payers including but not limited to credentialing, network status, contracting, billing, claims, and attribution.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Advise Manager/Director of questionable information received, and any issues identified during the processes.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Ensure billing departments are informed of updates and regulatory changes as it relates to insurance operations.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Gather and organize data, as needed, to support the preparation of fee schedule maintenance and negotiations.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Assist billing staff with review of denials, paper claim process, and billing.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Research and respond in person, by telephone, or in writing to patient or insurance carrier inquiries regarding billing questions.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Follow up with billing department on submitted claims, monitor unpaid claims, initiate tracers with EHR software, and re-file claims as necessary with standard billing cycle time frame, either electronically, on paper, or on insurance provider web portals.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Review and analyze patient records, keeping track of patient data over unpaid multiple visits.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Work and process appealed claims according to relevant insurance guidelines.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Review with billing and find solution to rejected and denied claims immediately to rule out a credentialing issue.&nbsp;</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Ensure strict confidentiality of records as per the Health Insurance Portability and Accountability Act of 1996 (HIPAA).</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Assist providers with credentialing inquiries.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Respond to health plan provider inquiries in a timely manner.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Follow compliance laws, regulations, procedures, and policies.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Conduct research on updated state and federal regulations and policies.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Release information to requesting agencies and public inquiries when required by law.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Help develop/update internal credentialing processes.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Ensure the facility and staff members are maintaining compliance with regulatory and accrediting institutions.</span></span></span></span></li>\r\n\t<li style=\"margin-left:8px;\"><span style=\"font-size:11pt;\"><span style=\"line-height:normal;\"><span style=\"font-family:Calibri, sans-serif;\"><span style=\"font-size:12pt;\">Perform other duties as assigned.</span></span></span></span></li>\r\n</ul>\r\n",
    "jobCategory": "Clinical Credentialing",
    "salaryRange": "$19.00 - $30.00 Hourly",
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