Provider Credentialing Specialist

Provider Credentialing Specialist

The Provider Credentialing Specialist is responsible for coordinating provider enrollment, credentialing maintenance, re-credentialing, hospital and facility credentialing, and ongoing payer and provider-data maintenance activities for healthcare providers across our client practices. This position manages provider information and documentation throughout the enrollment and maintenance lifecycle, including preparing and submitting payer, hospital, facility applications and rosters, maintaining CAQH and payer information, completing demographic updates, monitoring enrollment and credentialing activity, and following requests through completion.

Classification: Non-Exempt

Reports To: Director of Billing Services

Essential Job Functions & Responsibilities:

1. Prepare, complete, and submit provider enrollment applications, rosters, and other required documentation for government and commercial health plans.
2. Prepare and submit initial credentialing applications for hospitals and other healthcare facilities, as applicable.
3. Monitor enrollment and credentialing activity, respond to requests for additional information, and follow submissions through completion.
4. Complete and maintain applicable Medicare and Medicaid provider enrollment and maintenance activities, including new enrollments, reassignment or affiliation changes, demographic updates, revalidations, and other required submissions.
5. Prepare and submit demographic changes and other provider or practice updates to applicable payers and entities. Follow up as necessary to confirm changes have been processed accurately.
6. Maintain accurate and current provider information within CAQH, payer portals, and other applicable credentialing and provider-data systems.
7. Complete required attestations and verifications for applicable third-party sites, including Availity and BetterDoctor.
8. Update provider demographics, credentials, and supporting documentation as needed.
9. Monitor provider licenses, malpractice insurance, board certifications, and other applicable expirable credentials.
10. Provide timely renewal reminders and update renewed information with CAQH, payers, hospitals, credentialing systems, and other appropriate entities.
11. Coordinate and complete payer re-credentialing requirements, including obtaining provider information and documentation, preparing required submissions, responding to requests for additional information, and monitoring re-credentialing through completion.
12. Coordinate hospital and facility reappointment activities for applicable providers, including obtaining required information and documentation, completing and submitting applications and forms, monitoring deadlines, responding to requests for additional information, and following reappointments through completion.
13. Prepare and submit provider termination requests and related updates to applicable payers and entities when a provider is no longer affiliated with a client practice or when otherwise requested.
14. Review and respond to requests regarding provider enrollment and network participation using information maintained by the department.
15. Research discrepancies or conflicting information when payer, client, or other information does not align with department records.
16. Contact applicable payers or other entities as needed to verify information, document findings, communicate updates, and escalate complex issues as appropriate.
17. Maintain timely and accurate provider information, credentialing documentation, enrollment records, activity notes, follow-up dates, applicable data fields, and current status information within designated tracking systems and electronic files.
18. Communicate with health plans and other entities regarding pending enrollment, credentialing, demographic, or maintenance requests.
19. Research and resolve returned, rejected, delayed, or incomplete submissions.
20. Monitor processing timelines and deadlines, proactively escalating matters when expected timeframes are exceeded, deadlines are approaching, or routine follow-up has not resulted in resolution. Document follow-up and escalation activity through completion.
21. Provide timely enrollment, credentialing, re-credentialing, and maintenance status updates to clients. Request additional provider or practice information as needed, and proactively communicate and escalate issues when required information remains outstanding, deadlines are approaching, or completion or participation may be impacted.
22. Work collaboratively and professionally with physicians, client staff, payer representatives, hospital representatives, and internal team members to facilitate enrollment and credentialing activities.
23. Maintain provider, client, patient, and personnel confidentiality and comply with applicable company policies and regulatory requirements.
24. Maintain a high degree of professionalism, accuracy, ethical conduct, and confidentiality in all provider enrollment and credentialing activities.
25. Maintain regular and prompt attendance according to the agreed-upon work schedule.
26. Perform other duties as assigned.

Education & Experience:

• High School Diploma or equivalent.
• Prior experience with physician credentialing.
• Hands-on provider enrollment experience, including preparing and submitting payer enrollment requests and following submissions through completion.
• Ability to independently manage multiple providers, applications, follow-up requirements, deadlines, and competing priorities while maintaining accuracy and attention to detail.
• Strong organizational, documentation, research, problem-solving, and follow-up skills.
• Ability to communicate professionally with physicians, clients, payer representatives, and internal team members.
• Proficiency with Microsoft Word and Google Workspace applications, including Gmail, Docs, and Sheets, with the ability to learn payer portals, credentialing platforms, and internal tracking systems.

Preferred:

• Some college preferred.
• Experience with Medicare, Medicaid, commercial payer enrollment, and hospital/facility credentialing.
• Experience with CAQH, Availity, payer portals, and other provider enrollment or credentialing platforms.

Physical Demands & Work Environment Requirements:

The employee is routinely required to sit frequently, use a keyboard, mouse, telephone, headset, and other standard office equipment. Frequently communicate via text, email, phone, chat and video. The employee is occasionally required to sit; climb or balance; and stoop, kneel, crouch or crawl. The employee must frequently lift and/or move up to 25 pounds and occasionally lift and/or move up to 50 pounds. Works near others, usually within a few feet. This job will require occasional exposure to patient elements.

Expected Hours of Work:

The core hours of work are Monday – Friday with an 8-hour work shift between the hours of 8:00 a.m. and 5:00 p.m. Hybrid work opportunity available upon successful completion of in-office training. Subject to return to office if additional training is required.

Other Duties:

Please note this job description is not designed to cover or contain a comprehensive listing of activities, duties or responsibilities that are required of the employee for this job. Duties, responsibilities and activities may change as necessary.