Credentialing Specialist

Job Description

Job Description

JOB TITLE: Credentialing Specialist

REPORTS TO: Revenue Cycle Manager

FLSA STATUS: Non-Exempt

Position Summary

The Credentialing & Provider Enrollment Specialist is responsible for managing all aspects of provider credentialing, recredentialing, payer enrollment, hospital privileging, and provider maintenance to ensure uninterrupted reimbursement across all practice locations and service lines.

This position supports physicians and advanced practice providers practicing in office, ambulatory surgery centers, hospitals, pathology, anesthesia, infusion, and research services. The specialist serves as the primary liaison between the practice, payers, hospitals, credentialing organizations, and regulatory agencies to ensure providers remain compliant and eligible for reimbursement.

The ideal candidate has extensive experience with provider credentialing and enrollment, understands the financial impact of credentialing delays, and can proactively resolve payer enrollment issues before they affect revenue.

Minimum Qualifications

• Five or more years of physician credentialing and provider enrollment experience.
• Experience credentialing physicians and APPs with Medicare, Medicaid (optional) , and commercial payers.
• Experience with CAQH ProView, PECOS, NPPES, and state licensure processes.
• Experience using CredentialStream (required).
• Experience with Waystar or equivalent provider enrollment workflow platform (required).
• Experience with hospital medical staff applications and privileging.
• Knowledge of provider contracts, EFT enrollment, ERA enrollment, and payer participation.
• Strong understanding of revenue cycle implications related to credentialing and enrollment.
• Advanced Microsoft Office skills, including Excel.

Preferred Qualifications

• CPCS (Certified Provider Credentialing Specialist) or CPMSM certification.
• Experience in gastroenterology or multispecialty physician practices.
• Experience supporting ambulatory surgery centers, pathology, anesthesia, and infusion services.
• Familiarity with eClinicalWorks.

Essential Responsibilities

Provider Credentialing

• Prepare and submit initial credentialing applications.
• Complete recredentialing before expiration.
• Maintain credentialing files.
• Monitor license renewals and certifications.
• Coordinate DEA, state license, CDS, and board certification renewals.

Provider Enrollment

• Complete Medicare and Medicaid enrollment.
• Process commercial payer enrollments.
• Manage EFT and ERA enrollment.
• Coordinate group and individual provider enrollments.
• Maintain provider demographic information across all payer systems.

Hospital Privileging

• Coordinate hospital appointments and reappointments.
• Prepare medical staff applications.
• Track privileging expirations.
• Maintain hospital affiliations.

Revenue Cycle Support

• Resolve credentialing-related claim denials.
• Coordinate retroactive enrollments when appropriate.
• Work closely with Billing, Collections, Coding, and Contracting.
• Participate in payer calls and issue resolution meetings.
• Escalate enrollment issues that may delay reimbursement.

Contracting Support

• Assist with payer contract implementation.
• Coordinate provider participation status.
• Verify effective dates.
• Maintain payer participation matrix.

Systems Experience

Required experience with:

• CredentialStream
• Waystar
• CAQH ProView
• PECOS
• NPPES
• Medicare portals
• Florida Medicaid portal
• Commercial payer portals
• Microsoft Excel

Preferred:

• eClinicalWorks
• Availity
• Change Healthcare (or similar clearinghouse)

Key Performance Indicators (KPIs)

• Initial credentialing completed within established payer timeframes.
• Recredentialing completed before expiration.
• Zero credentialing-related interruptions in provider billing.
• Provider enrollment accuracy of at least 98%.
• EFT and ERA enrollment completed within 30 days of payer approval.
• Credentialing-related claim denials below 1%.
• Timely response to provider enrollment requests.

Core Competencies

• Strong analytical and organizational skills.
• Exceptional attention to detail.
• Ability to manage multiple providers and deadlines.
• Effective communication with physicians, hospitals, and payers.
• Knowledge of CMS and commercial payer requirements.
• Ability to work independently while collaborating with Revenue Cycle leadership.

Qualified individuals, please submit your resume.

We offer a competitive salary; Employee Health Insurance is covered at 100%. We also offer Dental, Vision, Life, and 401k Benefits.