POSITION SUMMARY

Under the direct supervision of the Chief Medical Officer (CMO) this position is responsible for coordinating, monitoring, and maintaining all aspects of provider credentialing, recredentialing, privileging, and enrollment activities for the Laguna Healthcare Corporation. This position ensures compliance with federal, state, tribal, payer, and accreditation requirements to support timely reimbursement and quality patient care. The Credentialing Specialist serves as the primary liaison between healthcare providers, insurance payers, regulatory agencies, and clinic leadership regarding credentialing and enrollment matters. Independent judgment is required to plan, prioritize and organize diversified workload. The Credentialing Specialist is expected to maintain confidentiality, demonstrate cultural sensitivity and contribute to the health center’s mission of providing quality, culturally appropriate healthcare.

ESSENTIAL FUNCTIONS 

1. Coordinate initial and ongoing credentialing, recredentialing, and privileging processes for all licensed healthcare providers.
2. Verify provider qualifications, education, training, licensure, certifications, work history, malpractice coverage, and professional references.
3. Maintain accurate provider credential files and electronic databases.
4. Monitor expiration dates for licenses, certifications, DEA registrations, CPR certifications, malpractice insurance, and other required credentials.
5. Prepare credentialing and privileging packets for review by clinic leadership and credentialing committees.
6. Track and ensure timely completion of credentialing and recredentialing requirements.
7. Complete and submit provider enrollment applications with Medicare, Medicaid, commercial insurance plans, and other third-party payers.
8. Coordinate enrollment, updates, and terminations with payer organizations.
9. Monitor application status and resolve enrollment issues to prevent disruptions in provider billing and reimbursement.
10. Maintain provider records within payer portals and enrollment systems
11. Ensure compliance with Indian Health Service (IHS), Centers for Medicare & Medicaid Services (CMS), Tribal 638 program requirements, and applicable accreditation standards.
12. Conduct regular audits of credentialing files and provider records for completeness and accuracy.
13. Maintain confidentiality of sensitive provider information in accordance with HIPAA and applicable regulations.
14. Assist with preparation for audits, surveys, and accreditation reviews.
15. Generate reports related to credentialing, provider enrollment, and compliance activities.
16. Serve as a resource to providers and clinic staff regarding credentialing requirements and processes.
17. Develop and maintain credentialing policies, procedures, and tracking systems.
18. Participate in departmental meetings, quality improvement initiatives, and special projects as assigned.

MINIMUM  QUALIFICATIONS

Experience: Two (2) years of experience in healthcare credentialing, provider enrollment, medical staff services or healthcare administration. Experience working in a Tribal, Indian Health Service (IHS), Federally Qualified Health Center (FQHC), Rural Health Clinic, or healthcare setting preferred. Experience working with Native American communities and a strong understanding of tribal sovereignty and tribal government preferred.

Education: Associate Degree in business administration, healthcare administration, health information management or related field.  Equivalent combination of education and experience may be considered.

License/Certification: Must possess or obtain Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) certification within one (1) year of employment.

Mandatory Knowledge, Skills, Abilities and Other Qualifications: To perform this job successfully, an individual must be able to perform each responsibility satisfactorily. These requirements are representative, but not all-inclusive, of the knowledge, skill, and ability required for this position.

• Knowledge of credentialing, privileging, and provider enrollment processes.
• Familiarity with Medicare, Medicaid, commercial payer enrollment requirements, and Tribal 638 healthcare programs.
• Understanding of healthcare regulatory and compliance standards.
• Strong organizational skills with exceptional attention to detail.
• Ability to manage multiple priorities and meet deadlines.
• Proficiency in Microsoft Office applications and credentialing software systems.
• Excellent verbal and written communication skills.
• Ability to maintain confidentiality and exercise sound judgment.
• Organizational and Planning Skills
• Excellent written and verbal communication skills and the ability to handle sensitive and confidential situations and documentation.
• Judgment and decision-making ability
• Initiative
• Solid analytical and problem-solving skills
• High attention to detail and accuracy
• Able to prioritize effectively and meet strict deadlines while managing multiple, competing tasks in a fast-paced organization.
• Strong team player able to form functional work relationships with peers and superiors.
• Knowledge of Microsoft Office Suite; Microsoft Word; Microsoft Excel; Microsoft Powerpoint; Microsoft Outlook; Microsoft Teams; Adobe Acrobat; design software; internet software; and electronic database systems.
• Basic operation of a workstation (knowledge of basic functions and components).
• Computer-related problem-solving skills through the use of available trainings and help desk.
• Knowledge of and understanding of HIPAA and the Privacy Act.
• Ability to function independently at times and the ability to be self- directed.
• Giving full attention to what other people are saying, taking time to understand the points being made, asking questions as appropriate, and not interrupting at inappropriate times.

PERFORMANCE EXPECTATIONS

In performance of their respective tasks and duties, an employee of Laguna Healthcare Corporation is expected to conform to the following:

1. Uphold all principles of confidentiality and patient care to the fullest extent.

2. Adhere to all professional and ethical behavior standards of the healthcare industry.

3. Maintain all licensures and certifications required of position.

4. Interact in an honest, trustworthy and respectful manner with patients, employees, visitors and vendors. 

5. Participate in Board of Director meetings, departmental staff meetings, quality management activities and educational programs as required.

6. Comply with Laguna Healthcare Corporation policies and procedures.

7. Maintain a current insurable driver’s license. 

WORK ENVIRONMENT

Work environment: The work environment characteristics described here are representative to those an employee encounters while performing the primary functions of this job. Normal office conditions exist, and the noise level in the work environment can vary from low to moderate. Limited overnight travel may be required from time to time and occasional travel for offsite meetings. May require flexible hours to accommodate clinical leadership schedules. This position may be exposed to certain health risks that are inherent when working within a health center facility, such as potential exposure to hazardous chemicals, sharps and infectious body fluids. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Physical demands: The physical demands are representative of the physical requirements necessary for an employee to successfully perform the essential functions of this job. While performing the duties of this job, the employee may be required to frequently stand, walk, sit, bend, twist, talk, hear and perform repetitive motions. There may be prolonged periods of sitting, keyboarding, reading, as well as driving or riding in transport vehicles. The employee must occasionally lift and/or move up to 30 pounds. Specific vision abilities required by this job include reading, distance, computer, and color vision. Talking and hearing are essential to communicate with patients, vendors and staff. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions. Operation of a motor vehicle required to travel between LHC facilities and perform other assigned off-site tasks.  

Mental demands: There are a number of deadlines associated with this position. The employee must be able to handle frequent interruptions and must also multi-task and interact with a wider variety of people on various and, at times, complicated issues.

TRIBAL PREFERENCE

The Laguna Healthcare Corporation has implemented Tribal Preference in Employment Policy. Pursuant to this Policy, applicants who possess the knowledge, skills, and abilities required by this position, and who are enrolled members of the Pueblo of Laguna will be given primary preference in hiring and employment for this position. Members of other Federally recognized Indian Tribes will be given secondary preference for hiring and employment after providing proof of Tribal membership. Tribal and Indian preference is integrated into the interview and scoring process for candidates for job positions.

OTHER

Confidentiality: All employees must uphold all principles of confidentiality to the fullest extent. This position will have access to sensitive information and a breach of these principles will be grounds for immediate termination.

Background Investigation: This position may be subject to a criminal history background check, a suitability background check and/or a Fair Credit Reporting Act (FCRA) check. In addition, some positions are subject to a more extensive background check to ensure compliance with Public Law 101-630 Indian Child Protection and Family Violence Prevention Act. Candidates must be able to successfully pass all required background checks to qualify for this position. A record of satisfactory performance in all prior and current employment as evidenced by positive employment references  from previous and current employers is also required.

Drug Screening: All applicants must successfully pass a pre-employment drug screening prior to beginning employment and will be subject to random drug testing.

Disclaimer: The information on this position description has been designed to indicate the general nature and level of work performance by employees in this position. It is not designed to contain, or be interpreted as, a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this position. Employees will be asked to perform other duties as needed.