Physician Enrollment & Credentialing Specialist

Job Description

Job Description

Company & Position Summary:       

Critical Care, Pulmonary and Sleep Associates is a multispecialty private physician practice, providing Critical Care, Pulmonary and Sleep medical services to the Denver metro area for over 40 years. Our dedicated team of Board-Certified Critical Care, Pulmonary and Sleep Physicians along with our skilled clinical and administrative staff exclusively serve nine Common Spirit and AdventHealth Hospital ICU’s and multiple outpatient clinic locations spanning Colorado’s front range. CCPSA’s organizational culture exemplifies excellence in patient centered care, unified teamwork, and a highly collaborative approach in all business and clinical operations. We are currently seeking a Physician Enrollment & Credentialing Specialist to join our committed team of professionals.

The Physician Enrollment & Credentialing Specialist is primarily responsible for provider credentialing, enrollment, appointment, and privileging across commercial insurance payers, government programs, hospitals, and other healthcare organizations.

This position ensures providers are appropriately credentialed, enrolled, appointed, and privileged to support timely reimbursement and uninterrupted patient care. In addition to credentialing responsibilities, this role supports revenue cycle operations through the research, appeal, and resolution of claim denials. The individual in this role partners with providers, internal teams, hospitals, and insurance carriers to maintain accurate provider records, meet credentialing and regulatory requirements, resolve reimbursement issues, and support efficient clinical and business operations. This role requires commitment to the CCPSA culture of collaboration while identifying opportunities for continuous improvement and supporting the organization's shared values.

Essential Responsibilities and Tasks:

Provider Credentialing, Enrollment & Privileging

• Ensure CCPSA providers are credentialed, enrolled, appointed, and privileged with commercial and government payers, hospitals, and other healthcare organizations to support uninterrupted clinical operations and timely reimbursement.
• Complete provider enrollment, credentialing, recredentialing, revalidation, appointment, privileging, and ongoing maintenance activities with commercial and government payers, hospitals, and other healthcare organizations.
• Coordinate provider onboarding activities related to credentialing and privileging, including hospital application requirements and other required pre-start activities, as applicable.
• Maintain credentialing records and monitor compliance with licenses, certifications, DEA registrations, malpractice coverage, continuing education, and other credentialing requirements.
• Maintain accurate provider information within credentialing systems, payer portals, hospital credentialing systems, CAQH, and other required databases.
• Ensure all credentialing files meet standards set by the NCQA, TJC, CMS, hospitals, and payer-specific guidelines.
• Serve as the primary point of contact for provider credentialing, enrollment, appointment, and privileging questions.

Denials Management

• Review denial queues and resolve claims accurately and promptly.
• Research and appeal denials using coding, records, contracts, payer guidelines, and documentation.
• Maintain expertise in payer portals, reimbursement rules, and appeals across commercial and government plans.
• Analyze denial trends and root causes to prevent recurrence.
• Escalate issues and report recurring trends or payer policy changes.
• Submit appeals within payer deadlines.
• Educate team members on payer updates, denial trends, and process improvements.
• Support quality initiatives that improve revenue cycle performance.
• Perform other duties as assigned.

Skills, Education and/or Work Experience Requirements:

• Minimum of two (2) years of experience in provider credentialing and/or payer enrollment required. Experience with hospital credentialing and privileging strongly preferred.
• Experience with medical billing, denial management, or other revenue cycle functions preferred.
• Experience researching, appealing, and resolving insurance claim denials preferred.
• Working knowledge of medical terminology, provider taxonomy, commercial and government payer guidelines, credentialing requirements, and healthcare reimbursement methodologies.
• Excellent analytical, organizational, problem-solving, and critical thinking skills.
• Demonstrated commitment to exceptional customer service through professional communication, responsiveness, and timely follow-up.
• Ability to work independently while effectively managing multiple competing priorities and consistently meeting deadlines.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Outlook, Word, Excel, internet research, and payer portals.
• Experience with EPIC Resolute Professional Billing strongly preferred.
• High School Diploma or GED required.

Compensation:

• Competitive hourly compensation.
• Benefits effective date-of-hire (no waiting period).
• Comprehensive medical benefits. Company covers 80-85% percent of individual or family premium.
• Dental and vision benefits offered at no cost to the employee. Company covers 100% of individual or family premium.
• Life and AD&D benefits.
• Optional additional life & disability insurance at group discounts.
• PTO and holiday pay.
• 401k benefits with company contribution after eligibility period.
• Position reports to RCM Manager.