Provider Credentialing Specialist - Procare

Job Description:

The Credentialing Specialist will be responsible for managing all credentialing and recredentialing activities for providers and facilities contracted with ProCare Advantage Institutional Special Needs Plan (ISNP). This role ensures compliance with CMS, NCQA, and state regulations while maintaining data accuracy across internal and external systems. The Specialist plays a critical role in supporting network expansion and maintaining network integrity.

Essential Responsibilities:

• Manage initial credentialing, recredentialing, and ongoing monitoring processes for providers and facilities.
• Verify provider credentials include licensure, education, training, board certification, work history, and malpractice history.
• Maintain and update provider files and databases, ensuring accuracy and regulatory compliance.
• Prepare credentialing applications, roster submissions, and track expirable such as licenses and insurance.
• Interface with providers, facilities, and internal teams to obtain and verify credentialing documentation.
• Coordinate credentialing committee reviews and prepare credentialing files for approval.
• Monitor federal and state exclusion lists, license verifications, and disciplinary actions on an ongoing basis.
• Collaborate with Contracting and Network Operations teams on new provider onboarding and network expansion projects.
• Generate and maintain credentialing reports and dashboards for leadership review.
• Ensure adherence to CMS, NCQA, and state-specific credentialing guidelines.
• Support internal and external audits related to credentialing compliance.
• Recommend process improvements to enhance credential efficiency and accuracy.

Required Qualifications:

• 3+ years credentialing experience in a healthcare organization, health plan, or skilled nursing setting preferred.
• Familiarity with CMS regulations, Medicare Advantage standards, and/or NCQA credentialing standards.
• Experience with credentialing software or database management systems.
• Highly organized, detail-oriented, and able to manage multiple priorities and deadlines.
• Strong communication and customer service skills.
• Proficient with Microsoft Office Suite (Excel, Word, Outlook).

Diversity, Equity, and Inclusion are at the heart of Cantex. We are committed to a culture that respects our differences and values the contributions of all people.

Please visitcantexcc.comfor more information about our organization.

We are an Equal opportunity employer; We offer an excellent benefit plan to include 401K with match, CEU reimbursement, vacation, sick, holidays, medical, dental, and supplemental insurance Plans as well as a Highly competitive compensation package.