Credentialing & Payer Enrollment Specialist

Job Description

Job Description

The Credentialing & Payer Enrollment Specialist is responsible for coordinating and maintaining timely and accurate provider credentialing, recredentialing and payer enrollment activities for CMEP physicians, advanced practice providers and other applicable providers.

The position serves as a primary liaison among providers, organizational departments and third-party payers to ensure providers are appropriately credentialed and enrolled and that provider information remains current. The position works closely with Human Resources, Medical Staff/Credentialing partners, Revenue Cycle, Finance and clinical departments to support timely provider onboarding and prevent enrollment-related disruptions to billing and reimbursement.

What You'll Do

• Coordinate provider credentialing and recredentialing activities.
• Complete and submit payer enrollment applications for commercial and governmental payers.
• Maintain provider enrollment records and monitor applications from submission through approval.
• Maintain and update CAQH provider profiles and attestations, as applicable.
• Coordinate Medicare, Medicaid and commercial payer enrollment, revalidation and demographic updates.
• Process provider additions, terminations and changes with applicable payers.
• Maintain accurate provider demographic, practice-location and enrollment information.
• Track licenses, DEA registrations, professional liability coverage, board certifications and other applicable provider credentials and expirable.
• Provide timely notification to providers and leadership regarding upcoming expirations or outstanding documentation.
• Coordinate with Human Resources and operational leadership regarding incoming and departing providers to support timely enrollment and disenrollment.
• Maintain payer rosters and reconcile provider participation information as necessary.
• Serve as a point of contact with payer representatives regarding provider enrollment and credentialing matters.
• Research and resolve enrollment discrepancies and communicate status updates to appropriate stakeholders.
• Partner with Revenue Cycle to identify and resolve claim issues resulting from credentialing or payer enrollment.
• Maintain organized electronic credentialing and payer enrollment records.
• Assist with payer audits and requests for provider credential information.
• Maintain appropriate confidentiality of provider information.
• Develop and maintain credentialing and enrollment procedures, tracking mechanisms and workflows.
• Produce periodic reports regarding pending enrollments, expirable, recredentialing and other key metrics.
• Provide administrative support for payer contracting activities, including maintaining payer contract inventories and tracking renewal dates, as assigned.
• Perform other related duties as assigned.

What You'll Bring

• Associate degree in Business, Healthcare Administration or related field preferred; equivalent relevant experience may substitute for education.
• Two or more years of healthcare credentialing, provider enrollment, medical practice administration or revenue-cycle experience preferred.
• Experience with commercial payers, Medicare and Medicaid enrollment strongly preferred.
• Experience with CAQH and electronic payer enrollment systems preferred.
• Knowledge of physician and advanced practice provider credentialing requirements.
• CPCS or related credentialing certification preferred but not required.

CMU is an AA/EO institution, providing equal opportunity to all persons, including minorities, females, veterans, and individuals with disabilities.