Payer Credentialing Specialist

Payer Credentialing Specialist

The Payer Credentialing Specialist is responsible for managing the full scope of payer enrollment and credentialing for healthcare providers across all payer platforms, including Medicare, Medicaid, and commercial insurers. This position ensures that providers are accurately and efficiently enrolled and credentialed to maintain compliance and timely reimbursement. The Specialist will also coordinate internal privileging processes and support the overall integrity of provider documentation.

Responsibilities and Duties

• Provider Credentialing & Onboarding
  • Manage initial credentialing and enrollment of providers with Medicare, Medicaid, and commercial payers.
  • Coordinate provider onboarding to ensure timely activation within all applicable payer systems.
  • Maintain accuracy of provider data across credentialing platforms and internal systems.
• Recredentialing & Maintenance
  • Track and manage recredentialing deadlines to ensure continuous payer participation.
  • Monitor expiring licenses, certifications, malpractice coverage, and other required documentation.
  • Ensure compliance with FQHC regulatory standards and payer-specific guidelines.
• FQHC Facility Credentialing
  • Oversee initial enrollment and revalidation of the FQHC facility with Medicare and Medicaid.
  • Maintain compliance with all CMS and state-specific regulatory requirements.
  • Manage site-level credentialing documentation and audits as required.
• Denial Management & Billing Collaboration
  • Partner with billing teams and external billing vendors to identify and resolve credentialing-related claim denials.
  • Investigate root causes of denials tied to enrollment or credentialing gaps and implement corrective action.
  • Support revenue cycle optimization by ensuring credentialing accuracy and timeliness.
• Data Management & Reporting
  • Maintain credentialing databases and tracking systems.
  • Utilize Excel and reporting tools to monitor credentialing status, expirations, and KPIs.
  • Generate timely reports for leadership related to credentialing performance and compliance.
• General Administrative Support
  • Organize and maintain credentialing files and documentation.
  • Ensure all processes align with organizational policies and regulatory requirements.

Qualifications

• Minimum of 3 years of experience in healthcare payer credentialing and provider enrollment.
• Working knowledge of credentialing requirements for Medicare, Medicaid, and major commercial payers.
• Familiarity with CAQH, PECOS, NPPES, and state Medicaid portals.
• Knowledge of regulatory and accreditation standards related to credentialing (e.g., NCQA, HRSA, CMS).
• Detail-oriented with excellent time management and organizational skills.
• Strong written and verbal communication abilities.
• Ability to handle sensitive information with professionalism and confidentiality.
• Proficiency in Microsoft Office Suite; experience with credentialing or enrollment software is a plus.

Education

• Associate degree required, bachelor's degree in healthcare administration, Business Administration, or a related field preferred.

Physical Requirements

• Ability to perform duties with or without reasonable accommodation.
• Must be able to sit, stand, and walk intermittently throughout the workday.
• Occasional bending, reaching, lifting (up to 30 lbs), and carrying of credentialing files or office materials.
• Manual dexterity and visual acuity required to perform data entry and document review tasks.

Working Environment

• Primary duties performed in a standard office environment with occasionally remote coordination.
• Requires frequent communication with internal departments, providers, and external credentialing bodies.
• May require occasional evening or weekend hours to meet enrollment deadlines or support onboarding timelines.
• Fast-paced environment with multiple deadlines and regulatory oversight.

Disclaimer: The above is intended to describe the job functions, the general supplemental functions and the essential requirements for the performance of this job. It is not to be construed as an exhaustive statement of supplemental duties, responsibilities, or non-essential requirements.

Medical Associates Plus is an Equal Opportunity Employer and does not discriminate against any employee or applicant because of race, color, sex, age, national origin, religion, sexual orientation, gender identity and/or expression, veteran status, basis of disability or any other federal, state or local protected class.