Credentialing & Authorization Specialist

Job Description

REQUIREMENTS

• 2+ years of experience in credentialing, prior authorizations, or insurance verification in a healthcare setting.
• Experience in behavioral health or substance use treatment settings is strongly preferred.
• Strong knowledge of insurance processes, payer requirements, and credentialing procedures.
• Experience with CAQH, Availity, or other insurance portals is a plus.
• Excellent organizational skills with strong attention to detail.
• Ability to manage multiple tasks and meet deadlines in a fast-paced environment.
• Proficiency in Microsoft Office (especially Excel) and electronic health records (EHR).
• Associate or Bachelor’s degree in Healthcare Administration or a related field preferred.

RESPONSIBILITIES

Credentialing

• Manage initial credentialing and re-credentialing for all providers (therapists, nurse practitioners, psychiatrists, etc.).
• Maintain updated provider profiles and logins across industry platforms like CAQH, PECOS, and NPPES.
• Maintain up-to-date CAQH profiles, NPI numbers, licenses, certifications, and malpractice insurance.
• Track license and certification expirations and ensure timely renewals.
• Coordinate provider enrollment with insurance panels and maintain accurate provider information across payers.
• Submit and manage provider enrollment applications and contracts with government (Medicare, Medicaid) and commercial managed care organizations
• Coordinate with Medical Directors, Human Resources, and billing teams to resolve credentialing discrepancies and ensure revenue cycle operations run smoothly

Prior Authorizations

• Submit and track prior authorizations for treatment services and medications, laboratory testing, IOP services, and other behavioral health treatments.
• Follow up on pending authorizations and work with insurance companies to obtain approvals or appeal denials.
• Maintain organized records of authorization status and communicate outcomes to the clinical team.

Verification of Benefits

• Verify insurance eligibility and benefits for new and existing clients.
• Document copays, deductibles, out-of-pocket maximums, and authorization requirements.
• Communicate benefit information clearly to clinical and administrative staff.

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