Credentialing Specialist (US Healthcare)

Credentialing Associate / Senior Credentialing Associate

Responsibilities

• Handle credentialing requirements for U.S. healthcare providers in the dental care space for in-network preferred providers.
• Manage all aspects of credentialing, recredentialing, and privileging processes for healthcare providers.
• Ensure providers meet all internal and external regulatory requirements, payer standards, and accreditation guidelines.
• Maintain accurate provider files, coordinate with insurance payers, and support compliance and quality initiatives.
  

Key Result Areas (KRAs)

• Coordinate and process initial credentialing, recredentialing, and privileging applications for physicians, allied health professionals, and other providers.
• Conduct Primary Source Verification of state licenses, DEA, and board certifications.
• Complete provider initial and recredentialing applications.
• Verify provider credentials including education, training, licensure, board certification, work history, malpractice history, and references.
• Maintain and update provider data in credentialing databases (e.g., CAQH).
• Ensure compliance with regulatory, accreditation, and payer requirements including NCQA, CMS, Joint Commission, and state agencies.
• Track license expirations, DEA certificates, malpractice insurance, and other credentials, and send timely renewal reminders.
• Prepare and present completed files for Credentialing Committee and Medical Executive Committee review.
• Coordinate payer enrollment and revalidation processes with insurance carriers.
• Respond to internal and external inquiries regarding provider credentialing status.
• Maintain confidentiality of provider information in accordance with HIPAA and organizational policies.
• Assist in developing and updating credentialing policies and procedures.
• Participate in audits and quality improvement initiatives as assigned.
• Demonstrate hands-on experience in federal and commercial payer application submissions including Medicaid, Medicare, and commercial payers.
  

Experience

• Experience in U.S.-based credentialing processes, with specialization in dental credentialing.
• Familiarity with the U.S. medical insurance industry.
• Experience with credentialing software systems: NPPES, PECOS, Availity, and CAQH ProView.
  

Additional Responsibilities (PDS Health)

• Check Deal Log bi-weekly for new office opening dates.
• Obtain IRS confirmation from the Development Department.
• Confirm Owner/Billing Provider with the VP of Operations.
• Verify current credentials on file for the Owner/Billing Provider.
• Request NPI Type 2 (Billing Entity NPI).
• Complete applications and contracts for the Billing Provider and submit for signatures.
• Review signed contracts for accuracy.
• Submit completed paperwork within 24 hours to applicable plans for approval and network acceptance.
• Update the credentialing process on the Pending Log.
• Follow up with dental plans.
• Process billing changes (ownership changes, PC changes, TIN changes).
• Credential owners, associates, and specialists as required.
• Maintain Insurance Provider Status Reports and provider files with current credentials.
• Manage inbound and outbound mail, including opening, sending, filing, and scanning.
• Communicate issues and suggestions to improve processes.
• Ensure compliance with company policies and with state, federal, and other regulatory bodies.

Location - DLF World Tech park DLF IT SEZ, NH8, Sector 30, Gurugram, Haryana 122001