Medical Credentialing Specialist

Job Description: The Medical Credentialing Specialist supports Foothills Neurology’s Billing and Finance Department by managing all aspects of provider credentialing, payer enrollment, contracts, and credentialing. This position ensures that all physicians, nurse practitioners, hospitalists (if required) and physician assistants are accurately credentialed and actively enrolled with contracted insurance plans to maintain uninterrupted reimbursement and compliance. The ideal candidate is detail-oriented, self-motivated, professional, with high standards of confidentiality and able to manage multiple credentialing timelines while maintaining thorough documentation and communication across departments. Key Responsibilities Verify licenses, prepare and submit initial credentialing, re-credentialing, and payer enrollment applications for all providers and practice locations. Maintain up-to-date provider records, including licenses, DEA, NPI, NPBD, CEV’s board certifications, malpractice insurance, and CAQH profiles. Manage expirations, renewals, -re-applicationsand re-attestations deadlines to ensure compliance with payer and regulatory requirements. Conduct primary source verification and maintain accurate digital credentialing files. Resolve directly with payers, providers, hospital partners and internal departments applicationor enrollment issues Coordinate with HR during provider onboarding and terminations to ensure timely credentialing actions. Collaborate closely with billing and revenue cycle teams to confirm provider enrollment aligns with payer rosters and reimbursement rules. Prepare regular status reports and updates for leadership regarding pending applications, revalidations, and upcoming expirations, enrollments, and closures to maintain accurate panel status. Support audits, compliance checks, and payer correspondence in a timely manner as needed. Stay updated on changes in managed care regulations and medical terminology to ensure best practices are followed. Maintain adherence to professional confidentially standards established within the Department and in accordance with legal, ethical, hospital and medical staff policies.Assures data security and confidentiality by using appropriate labeling of information and storage and appropriately securing cabinets and drawers. Locate and identify key contacts for payers and hospitals. Maintain credentialing grid/database. Perform a check on contracts to make sure appropriate fee schedules for area are utilized. Perform other duties assigned by supervisor or management to support operational and organizational needs. Required Education: Education: High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred. Required Experience: Minimum of 2 years of credentialing and/or payer enrollment experience in a healthcare or medical practice environment. Knowledge of insurance payer processes, NCQA standards and accreditation processes, CAQH, Medicare provider applications, NPPES/PECOS, and credentialing software systems. Familiarity with CMS, commercial insurance, and Medicaid enrollment processes preferred. Requested Qualifications/Skills: Strong attention to detail and accuracy. Process mindset: Experience building SOP’s and improving operation workflow. Excellent organizational and deadline management skills. Professional written and verbal communication. Ability to work independently and maintain confidentiality. Proficiency in Microsoft Office (Word, Excel, Outlook). Why Join Us At Foothills Neurology, we value a culture of collaboration, service, and continuous improvement. As the Credentialing Specialist, you’ll play a pivotal role in shaping our billing operations and driving positive outcomes for our patients and our practice.