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Position Summary

The Medical Staff Credentialing Specialist is responsible for the full credentialing and re-credentialing lifecycle for physicians, allied health professionals, telehealth providers, and locum tenens practitioners at Madera Community Hospital. This position ensures every practitioner granted clinical privileges has been verified, vetted, and appointed in accordance with Medical Staff Bylaws, hospital policies, NCQA standards, Joint Commission requirements, CMS Conditions of Participation, and California state law.

The Specialist serves as the primary subject-matter expert on credentialing within the Medical Staff Office and is expected to own the credentialing function end-to-end - driving timelines, managing the file queue, coordinating workflow across stakeholders, and ensuring files are committee-ready without daily oversight. This role exercises significant independent judgment and process ownership while reporting to the Director of Medical Staff Services.

Essential Duties and Responsibilities

Credentialing & Re-credentialing

• Process initial appointment, reappointment, and privilege modification applications for all medical staff and allied health categories within established turnaround times.
• Conduct primary source verification of education, training, board certification, licensure, DEA, work history, malpractice claims, NPDB queries, OIG/SAM/Medi-Cal sanctions checks, and references.
• Review applications for completeness, identify red flags, and follow up directly with applicants and verification sources to resolve gaps.
• Prepare credentialing files for review by department chairs, the Credentials Committee, Medical Executive Committee, and the Governing Board.
• Maintain expirables tracking (license, DEA, board certification, malpractice insurance, BLS/ACLS/PALS) and proactively notify practitioners well in advance of expiration to prevent lapses in privileges.

Process Ownership & Workflow Coordination

• Own the day-to-day credentialing workflow, including prioritization of the file queue, assignment of verification tasks, and escalation of files at risk of missing committee deadlines.
• Serve as the point of contact for department chairs, hospital administration, the CVO, and external entities on credentialing matters and file status.
• Coordinate the work of credentialing support staff and outside CVO vendors on assigned files, providing direction on file build, verification standards, and quality checks (without formal supervisory authority).
• Mentor and provide training to new Medical Staff Office staff on credentialing standards, software workflows, and regulatory requirements.
• Lead process improvement initiatives within the credentialing function - including identifying bottlenecks, recommending policy or workflow changes, and implementing approved changes.
• Develop and maintain credentialing desktop procedures, checklists, and standard work documents.

Committee & Meeting Support

• Coordinate logistics, agendas, file packets, and minutes for the Credentials Committee and assist with Medical Executive Committee preparation as it relates to credentialing matters.
• Track committee action items and follow through to closure.
• Prepare credentialing reports, dashboards, and KPI summaries (turnaround time, file aging, denial rate, expirables compliance) for leadership and committee review.

Compliance & Audit

• Ensure ongoing compliance with Joint Commission, CMS, NCQA, CDPH, and Medical Staff Bylaws standards.
• Serve as the primary credentialing point of contact during Joint Commission surveys, CDPH inspections, and payer audits.
• Conduct internal file audits to confirm files meet regulatory and bylaws requirements; identify and correct deficiencies.
• Maintain confidentiality of all peer review, quality, and credentialing information in accordance with California Evidence Code 1157 and HIPAA.

Payer Enrollment Coordination (as assigned)

• Coordinate with the payer enrollment team or vendor to ensure newly credentialed providers are enrolled with Medicare, Medi-Cal, and contracted commercial/managed care plans in alignment with the start date.

Other

• Maintain the credentialing database (MD-Staff, Cactus, Echo, MSOW, or equivalent) and ensure data integrity.
• Respond to verification requests from outside hospitals, payers, and licensing boards.
• Perform other duties as assigned by the Director of Medical Staff Services.

Minimum Qualifications

Education

• High school diploma or equivalent required.
• Associate or Bachelor's degree in Healthcare Administration, Business, or related field preferred.

Experience

• Minimum of three (3) years of hands-on hospital medical staff credentialing experience required.
• Experience in an acute care hospital Medical Staff Office strongly preferred.
• Demonstrated experience independently managing a credentialing file caseload from application through board approval.
• Experience coordinating the work of others, mentoring junior staff, or serving as a lead/senior on a credentialing team preferred.

Knowledge, Skills, and Abilities

• Strong working knowledge of Joint Commission MS standards, CMS Conditions of Participation, NCQA credentialing standards, and CDPH licensing requirements for general acute care hospitals.
• Working knowledge of California Medical Staff Bylaws structure, Business & Professions Code 805 reporting, and 1157 peer review confidentiality protections.
• Proficiency with credentialing software (MD-Staff, Cactus, Echo, MSOW, Symplr, or equivalent).
• Familiarity with NPDB query and reporting requirements, CAQH, and primary source verification standards.
• High level of accuracy, attention to detail, and ability to manage a complex file queue with competing deadlines.
• Strong written and verbal communication skills, including the ability to professionally interface with physicians, executive leadership, and external verifying entities.
• Ability to work independently, exercise sound judgment, and escalate appropriately.
• Proficient with Microsoft Outlook, Word, and Excel.

Preferred Qualifications

• Certified Provider Credentialing Specialist (CPCS) through NAMSS - strongly preferred.
• Certified Professional Medical Services Management (CPMSM) through NAMSS - preferred.
• Experience preparing for and participating in Joint Commission triennial surveys.
• Experience supporting telemedicine credentialing-by-proxy arrangements.
• Experience with payer enrollment processes (Medicare PECOS, Medi-Cal PAVE, CAQH ProView).