Credentialing Specialist

Job Summary

The Payer Credentialing Specialist is responsible for coordinating and managing all provider credentialing, enrollment, and re-credentialing activities with third-party payers to ensure timely and accurate claims processing and reimbursement. This position maintains provider enrollment records, submits and tracks payer applications, manages credentialing databases, and serves as a liaison among providers, payers, Physician Billing, Medical Staff, Finance, Information Technology, and other departments. The Payer Credentialing Specialist ensures compliance with payer requirements, NCQA standards, Joint Commission guidelines, and organizational policies while supporting revenue cycle operations through accurate credentialing and provider enrollment maintenance.
Responsibilities of the Position

• Coordinate, manage, and follow up on all payer credentialing and provider enrollment activities.
• Complete payer enrollment and credentialing applications and provide required documentation on behalf of employed providers.
• Maintain provider participation with all contracted payers through timely re-credentialing and enrollment updates.
• Obtain, update, organize, and maintain provider credentialing documentation and records.
• Manage provider files using Excel spreadsheets, Word documents, CAQH, and CACTUS software.
• Complete and maintain provider CAQH profiles utilizing primary source verification in accordance with NCQA and Joint Commission standards.
• Track credentialing, enrollment, and documentation requirements through spreadsheets and reporting tools.
• Communicate regularly with payers regarding provider enrollment status, application processing, and credentialing issues through telephone, email, fax, and written correspondence.
• Maintain provider rosters and generate reports using available credentialing databases and software.
• Demonstrate understanding of Joint Commission (JCAHO) standards related to Medical and Dental Staff credentialing processes.
• Respond to credentialing inquiries and provide timely support to providers, Medical Staff, and internal departments.
• Serve as a liaison between payers, Finance, Revenue Cycle, Physician Billing, and other key departments regarding credentialing and enrollment matters.
• Provide information and support regarding payer credentialing issues to leadership as requested.
• Create and maintain provider files and enrollment records utilized by physician and hospital billing staff.
• Assist office managers, providers, and billing staff with resolving payer enrollment and credentialing issues impacting claims reimbursement.
• Complete assigned duties in accordance with departmental policies, procedures, and productivity expectations.
• Complete all required organizational and departmental training.
• Provide excellent customer service and collaborate effectively with internal and external stakeholders.
• Adhere to patient privacy, confidentiality, and information security policies and procedures.
• Support organizational initiatives and adhere to Making Ellis Exceptional (MEE) Behaviors & Standards and AIDET principles.
• Perform additional duties as assigned.

Education and Experience Requirements

Education:

• High School Diploma or equivalent required.
• Associate Degree preferred.

Experience:

• Two (2) years of experience in a healthcare environment preferred.
• Experience with payer credentialing, provider enrollment, and medical terminology preferred.

Knowledge, Skills, and Abilities:

• Proficiency with Microsoft Word, Excel, and other Windows-based applications required.
• Experience maintaining databases and preparing accurate reports.
• Knowledge of healthcare credentialing processes, payer enrollment requirements, and provider data management preferred.
• Ability to prioritize multiple tasks and meet deadlines in a fast-paced environment.
• Strong verbal and written communication skills.
• Excellent organizational, customer service, and interpersonal skills.
• Ability to work independently and collaboratively within a team environment.

Certification:

• None required.

Ellis Medicine is committed to creating a diverse environment and is proud to be an equal opportunity employer. All qualified applicants will receive consideration for employment without regard to, and will prohibit, discrimination on the basis of race, creed, color, religion, sex/gender (including pregnancy), age, national origin, disability (including pregnancy-related conditions), genetic information, predisposition or carrier status, military or veteran status, prior arrest or conviction record, marital or familial status, sexual orientation, transgender status, gender identity, gender expression, reproductive health decisions, domestic violence victim status, known relationship or association with any member of a protected class, and any other characteristic protected by applicable law violates federal, state and, where applicable, local laws , reproductive health decisions or source of payment, consistent with applicable legislation and to comply with the laws pertaining thereto.

Salary Range: $17.46-$25.32/hour Pay is based on experience, skills, and education. Exempt positions under the Fair Labor Standards Act (FLSA) will be paid within the base salary equivalent of the stated hourly rates. The pay range may also vary within the stated range based on location.