Credentialing Specialist

The Health and Human Services Credentialing Specialist under the general supervision of the Quality and Compliance Administrator supports the onboarding and off-boarding of all medical and behavioral health staff working within HHS. This position specifically relates to the privileging and credentialing and re-credentialing of providers (i.e. physicians, physician assistants, ARNPs, dentists, licensed counselors, etc.) in accordance with applicable licensing board and/or accreditation standards. This job class is treated as FLSA Non-Exempt.

Essential Functions: (Essential functions may vary among positions, but may include the following tasks, knowledge, skills, abilities, and other characteristics. This list of tasks is ILLUSTRATIVE ONLY and is not intended to be a comprehensive listing of tasks performed by all positions in this classification.)

1. Provider Credentialing and Enrollment: Manage initial credentialing and recredentialing, and prepare and submit credentialing applications to facilitate the enrollment process for insurance payors for:

• Physicians (MD/DO)
• Nurse Practitioners (NP)
• Physician Assistants (PA)
• Licensed Behavioral Health Providers (PhD, PsyD, LCSW, LPC, LMFT, etc.)

2. License and Certification Verification: Verify and maintain records, and ensure credentials remain active and in good standing for:

• Professional licenses
• DEA registrations (if applicable)
• Board certifications
• CPR/BLS certifications
• Fingerprint clearance cards

3. Regulatory Compliance: Ensure regulatory compliance, and maintain audit-ready files for inspections and payer reviews, with:

• Arizona Department of Health Services
• AHCCCS provider requirements
• DDD and DCS standards (as applicable)
• Federal healthcare regulations

4. Recredentialing & Monitoring: Track expiration dates, and ensure timely renewals for the re-credentialing and re-privileging process for:

• Licenses
• Certifications
• Provider enrollments

5. Payer Enrollment & Contracting Support: Assist with, and track application status and resolve delays with:

• New provider enrollment
• Group enrollment updates
• Credentialing follow-ups with payers

6. Provider File Management: Maintain accurate and complete provider credentialing files. Ensuring documentation includes:

• Applications
• Verification records
• Contracts
• Training and compliance records

7. Collaboration & Communication: Ensure providers are fully credentialed before rendering services, provides administrative support (agenda, minutes, etc.) to committees, and work closely with:

• HR (hiring and onboarding)
• Billing and revenue cycle team
• Clinical leadership

8. Continuous Quality Improvement& Risk Management: Participate in quality improvement initiatives (FPPE, OPPE, Peer Review). Prevent credentialing-related compliance risks. Ensure no provider renders services without proper credentialing. Maintain strict confidentiality of provider information. Prepare for:

• ADHS inspections
• AHCCCS audits
• Internal compliance reviews

9. Miscellaneous: Other job-related duties as assigned to improve departmental operations or efficiencies. 

Knowledge, Skills, Abilities, and Other Characteristics:

• Knowledge of the history, customs, culture, traditions and government of the Salt River Pima- Maricopa Indian Community.
• Knowledge of healthcare credentialing and privileging.
• Skill in analyzing data from multiple sources?
• Skill establishing and maintaining effective working relationships with medical staff and leadership.
• Skill with verbal and written communication, numbers and record keeping
• Skill using personal computer and related software.

• Skill in solving problems through the use of a combination of delivered and custom-developed tools.?
• Skill in time management and organization.

• Ability to code, compile and categorize, and verify information/data.
• Ability to work independently, take initiative and use judgment.
• Ability to meet and comply with HIPAA/Confidentiality policies and procedures and ability to handle highly confidential and sensitive information.
• Ability to complete work assignments and special projects in a timely manner.?

Education & Experience - Associate’s degree, in related field and one (1) year full-time experience in managing credentialing, privileging, or similar healthcare professional verification and organization’s accreditation processes are required.

• Bachelor’s degree in related field preferred,
• Experience working with Native Americans strongly preferred.
• Certified Provider Credentialing Specialist (CPCS) Preferred within one (1) year or within six (6)months of becoming eligible to sit for exam.

Equivalency: Any equivalent combination of education and experience that will allow the applicant to satisfactorily perform the duties of the job may be considered.

Underfill Eligibility: An enrolled Community Member whom closely qualifies for the minimum qualifications for a position may be considered for employment under SRPMIC Policy 2-19, UnderfillMay be required to work beyond normal work hours including nights, weekends and holidays. 

• Employees in, and applicants applying for, jobs providing direct services to children are subject to the “Community Code of Ordinances”, Chapter 11, “Minors”, Article X. “Investigation of Persons Working With Children”.
• Ensures all patient information is kept confidential and complies with Health Insurance Portability and Accountability Act (HIPAA) regulations and SRPMIC HHS policies and procedures.