Credentialing Specialist

Overview

Join Affiliated Oncologists as a Credentialing Specialist! AO specializes in treating a variety of cancers including lymphoma lung, breast, prostate, gynecologic, colorectal and head and neck cancers. Our physicians and staff are a multi-disciplinary team of highly experienced caregivers focused on helping patients and their families receive the best care and support possible.

SCOPE: Under general supervision, oversees, maintains and coordinates actions for physician credentialing, licensure and hospital privileges activities. Supports and adheres to the US Oncology Compliance Program, to include the Code of Ethics and Business Standards. The Credentialing Specialist is responsible for the complete lifecycle of provider and entity credentialing and payer enrollment across a multi‑specialty oncology practice. This role ensures providers are accurately credentialed, re‑credentialed, and enrolled with commercial, Medicare, Medicaid, and specialty oncology payer programs to enable timely reimbursement and compliant patient access.

In addition, the role provides structured administrative support to team leads and management (e.g., meeting logistics, tracking deliverables, reporting) to keep operational initiatives on schedule. This role collaborates closely with Revenue Cycle, Provider Onboarding, Compliance, Medical Staff Services, Contracting, and Payer Relations to reduce delays, prevent denials, and maintain continuous payer participation.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

Credentialing & Enrollment (Primary)

• End‑to‑end provider/entity credentialing:
  Collect, verify, and maintain credentials for physicians, advanced practice providers (APPs), pharmacists, infusion RNs (as applicable), and practice entities (group, locations, lab, radiation, etc.).
• Payer enrollment & re‑enrollment:
  Prepare and submit enrollment applications (commercial payers, Medicare PECOS, Medicaid, specialty oncology programs); manage effective dates; track approvals.
• Primary Source Verification (PSV):
  Validate licensure, DEA, CSR, board certifications, NPDB queries, OIG/SAM exclusions, malpractice history, hospital affiliations, and CAQH profiles.
• CAQH & PECOS management:
  Create/maintain provider profiles; ensure data integrity; manage reattestations and digital signatures.
• Taxonomy & NPI management:
  Coordinate Type 1/Type 2 NPIs; taxonomy codes; ensure alignment with contracts and billing requirements.
• Location & roster maintenance:
  Keep payer rosters current (adds, terms, specialties, locations, telehealth flags); submit updates promptly.
• Recredentialing cycles:
  Maintain calendars for deadlines; initiate recredentialing packets and PSV in advance; avoid lapses.
• Contract alignment:
  Partner with Contracting/Payer Relations to ensure credentialed specialties and locations match executed agreements and fee schedules.
• Denial prevention:
  Collaborate with Revenue Cycle to resolve “provider not enrolled/credentialed” denials; implement corrective actions and upstream fixes.
• Audit & compliance:
  Maintain documentation for internal/external audits (e.g., NCQA/URAC elements if applicable, Medicare/Medicaid participation requirements).
• Data integrity:
  Maintain credentialing database/worklists; update EHR/practice management systems and clearinghouse where applicable.

Administrative Support to Team Leads & Management (Secondary)

• Meeting & workflow coordination:
  Schedule meetings, prepare agendas, capture minutes/action items, track deliverables, and follow‑ups.
• Reporting & dashboards:
  Produce weekly/monthly status reports (e.g., application aging, effective dates, PSV completion, payer approvals); distribute to stakeholders.
• Document management:
  Organize shared drives, credentialing files, SOPs, templates, and version control; manage e‑signature workflows.
• Intake & communication:
  Triage requests (provider additions, changes, terminations); maintain communication templates; provide updates to providers and internal teams.
• Process improvement:
  Assist in SOP updates, checklists, and training materials; identify bottlenecks and propose solutions.
• Vendor & portal support:
  Maintain portal access (CAQH, PECOS, Medicaid, payer…