Credentialing and Enrollment Specialist

Description

Position Overview

A successful Credentialing and Enrollment Specialist (CES) must be passionate about healthcare and want to make a difference in the lives of others while acting as a mission-driven catalyst to help Livingston Community Health (LCH) deliver the best quality of care and excellent service to our patients and their families.


The Credentialing and Enrollment Specialist is responsible for coordinating and managing all aspects of provider credentialing, re-credentialing, privileging, and payor enrollment at the Federally Qualified Health Center (FQHC). Also, responsible for facility, site, and service-line licensing.

Essential Functions, Duties, and Responsibilities

Ensures the organization maintains compliance with HRSA, FTCA, CMS, NCQA, and other applicable regulatory and accrediting bodies, facilitating timely provider onboarding and payor enrollment. Responsible for facility, site, and service-line licensing, ensuring timely renewals, accurate postings, and alignment with payer/site enrollments.

Credentialing & Privileging

• Manage the full credentialing lifecycle for licensed providers and other credentialed staff, including initial credentialing, primary source verification, and recredentialing every two years.
• Coordinate the privileging process, ensuring all privilege requests are complete, appropriately reviewed, and approved by the Board of Directors.
• Maintain accurate and complete provider files, credentialing database, and credentialing software systems.
• Track and verify license, DEA, BLS, malpractice insurance, board certifications, NPDB, and other required documents to ensure ongoing compliance.
• Coordinate and track annual peer review results and ensure the Chief Medical Officer (CMO) reviews and incorporates them into the recredentialing and reprivileging process.
• Prepare reports for the Quality Committee, Medical Executive Committee, and Board of Directors regarding credentialing and privileging status.

Payor Enrollment

• Manage enrollment and re-enrollment with all contracted health plans (Medicaid, Medicare, and commercial insurers).
• Prepare, submit, and track all enrollment applications, including provider adds, terminations, demographic updates, and reassignment of benefits.
• Maintain accurate payor rosters and CAQH profiles for all providers.
• Monitor effective dates and ensure billing and reimbursement are not delayed.
• Collaborate with the billing and revenue cycle teams to resolve enrollment-related claim denials.

Facility Licensing

• Maintain a comprehensive inventory of all organizational facility, site, and service-line licenses/permits/registrations, including license numbers, effective/expiration dates, scope of services, locations, and required postings.
• Prepare, submit, and track initial applications and renewals for facility and service-line licenses (e.g. clinic license, CLIA, radiology, lab, DME, pharmacy and local business licenses), preventing lapses and interruptions in operations.
• Manage Medicare/Medicaid revalidations and state enrollment renewals for facilities.
• Maintain a centralized, audit-ready license repository and ensure current postings at each site; respond to payer, regulator, or accreditor requests within stated timelines.

Compliance & Auditing

• Ensure credentialing, privileging, and enrollment activities are compliant with HRSA, FTCA, state and federal regulations, and internal policies.
• Maintain audit-ready files and documentation to support HRSA Operational Site Visits (OSVs), FTCA deeming applications, and external audits.
• Maintains compliance with CMS and NCQA regulatory bodies.
• Develop, implement, and maintain standard operating procedures (SOPs) for credentialing, privileging, and payor enrollment functions.

Communication & Collaboration

• Serve as the primary point of contact for providers regarding their credentialing, privileging, and enrollment status.
• Partner with Human Resources, Medical Leadership, Revenue Cycle, and Compliance to coordinate provider onboarding and ensure accurate information is shared across departments.
• Provide regular status updates and reporting to leadership on credentialing and enrollment activities.
• Supports the overall needs of the organization by working flexible or extended hours when necessary.
• Demonstrates competence with the mission, vision, and values of the organization in providing quality services to the community.
• Other work-related duties as assigned. Duties and responsibilities may be added, deleted, or changed at any time at the direction of leadership, formally or informally, either verbally or in writing.
• Maintains confidentiality and respect for all sensitive information.
• Displays a positive, professional, and respectful demeanor at all times towards employees, peers, professional contacts, and patients served, maintaining a professional appearance and positive image for LCH.
• Contributes as part of the team by promoting positive staff interactions and maintaining open communication with other programs and departments.
• Attends and actively participates in all meetings (e.g., department meetings, program meetings, staff meetings) and other activities as required or assigned.

Education, Knowledge, Skills, and Abilities

Education and Experience

• High school diploma or equivalent required; Associate or Bachelor's degree preferred.
• Minimum of three years' experience in credentialing and/or payor enrollment, preferably in an FQHC or multi-specialty clinical setting.

Certification

• Certified Provider Credentialing Specialist (CPCS), required within 18 months of hire.
• Certified Professional Medical Services Management (CPMSM) preferred.

Knowledge, Skills, and Abilities

• Working knowledge of HRSA, FTCA, CMS, and NCQA credentialing and privileging requirements.
• Strong organizational skills with excellent attention to detail and accuracy.
• Proficiency in credentialing/enrollment software, Microsoft Office Suite, and CAQH ProView.
• Ability to handle sensitive information with discretion and maintain strict confidentiality.
• Strong written and verbal communication
• Ability to manage competing deadlines in a fast-paced environment
• High degree of problem-solving and follow-through
• Minimum of three years' experience in credentialing and/or payor enrollment, preferably in an FQHC or multi-specialty clinical setting.