Credentialing Specialist

Paradigm is an accountable specialty care management organization focused on improving the lives of people with complex injuries and diagnoses. The company has been a pioneer in value-based care since 1991 and has an exceptional track record of generating the very best outcomes for patients, payers, and providers. Deep clinical expertise is the foundation for every part of Paradigm’s business: risk-based clinical solutions, case management, specialty networks, home health, shared decision support, and payment integrity programs.

We’re proud to be recognized—again! For the fourth year in a row, we’ve by Great Place to Work®, and for the third consecutive year, we’ve earned a spot on . These honors reflect our unwavering commitment to fostering a positive, inclusive, and employee-centric culture where people thrive.

Watch this for a brief introduction to Paradigm.

We are seeking a full-time, hybrid Credentialing Operations Specialist. The Credentialing Operations Specialist is responsible for providing administrative and technical expertise to credentialing services and functions.

Demonstrates a customer-first mindset through a commitment to delivering the best possible outcomes for our customers, which include; injured workers, payors, clients, providers, stakeholders, and internal teams. By fully leveraging Paradigm’s solutions, delivering consistently high‑quality service, and collaborating effectively with internal and external partners, we create an exceptional customer experience.

RESPONSIBILITIES:

• Completes credentialing and re-credentialing application process of all internal and affiliated community practitioners.
• Processes request, investigation, verification, tracking and follow up of primary responses from various sources.
• Identifies, investigates, reports, tracks, and follows-up on any potentially adverse information received from credentialing sources.
• Obtains and maintains appropriate knowledge of company policy and procedures, accreditation standards, state and federal regulations, guidelines, procedures and laws required in credentialing process.
• Populates, updates, and maintains credentialing software and filing systems.
• Assists with Requests for Proposals or any requested reports as necessary and in collaboration with supervisor or other Credentialing Services staff.
• Maintains practitioner files annually.
• Ensures medical licenses, DEA certificates and malpractice certificates are current at all times for affiliated community practitioners.
• Works with designated QAIR Peer Review and Member Services personnel prior to each Credentialing/Peer Review meeting and continuously coordinates Peer Review information into credentialing and re-credentialing files.
• Collects site visit information from Provider Relations on appropriate practitioner files in preparation for Credentialing/Peer Review Committee approval meetings.
• Works with Risk Management to identify and coordinate any risk management, substance abuse and/or malpractice issues. Reviews files for any "red flag" issues.
• Prepares practitioner profiles and completes permanent file for review and approval at each Credentialing/Peer Review Committee meeting.
• Participates in professional organizations and/or other organizations addressing credentialing, compliance and/or risk management activities.
• Maintains strict confidentiality of all records, data and occurrences as condition of initial and/or ontinued employment.
• Maintain reliable and predictable attendance during scheduled work hours.
• Utilizes AI tools to support day-to-day tasks, improve efficiency, and enhance output quality. Adopts new technologies as trained and applies them in alignment with established processes and guidelines.
• Demonstrates a customer-first mindset by developing a broad and deep (where appropriate) understanding of Paradigm organization, products, operations, and customers. Prioritizes collaboration to meet customer needs and expectations and takes personal accountability for service quality.
• Responsible for complying with Paradigm Information Security requirements and policies, for safeguarding Paradigm or Paradigm related passwords, and for notifying Paradigm of any Information Security incidents per policy SEC 10-12 Information Security Incident Management.

QUALIFICATIONS:

• Bachelor's degree in health care or technical field preferred, call center experience a plus.
• Exceptional communication and telephone skills required, as well as a great deal of patience and understanding.
• Experience working with physicians and/or senior executives preferred.
• Possess a high level of self-confidence and persistence; maintain an assertive approach in dealing with providers.
• Must possess excellent organizational skills and the ability to multi-task effectively.
• Demonstrate the ability to prioritize heavy workload and work independently with minimal supervision.
• Proficient computer and internet skills; familiarity with Microsoft Office software required.
• Knowledge of medical terminology preferred.
• Certified Provider Credentialing Specialist (CPCS) or Certified Medical Staff Coordinator (CMSC) by the National Association Medical Staff Services (NAMSS) preferred.
• Will develop in-depth knowledge of department and company internal workflows including, but not limited to individual state’s procedures and negotiating protocols.
• Bilingual a plus.