Provider Credentialing Specialist

The Provider Credentialing Specialist is responsible for managing the credentialing, recredentialing, and payer enrollment processes for healthcare providers.

This role ensures compliance with regulatory, accreditation, and insurance requirements by maintaining accurate provider records, monitoring credential expirations, managing CAQH profiles, and coordinating provider enrollment with Medicare, Medicaid, and commercial insurance carriers.

The specialist serves as a key liaison between providers, payers, and internal teams to support timely onboarding and uninterrupted reimbursement.

Responsibilities:

• Manage end-to-end provider credentialing and recredentialing processes, ensuring timely and accurate submissions.
• Complete and submit applications for initial credentialing, recredentialing, and payer enrollment.
• Verify provider credentials, including medical licenses, DEA registrations, board certifications, education, training, work history, and malpractice insurance.
• Maintain organized and audit-ready credentialing files and documentation.
• Coordinate provider enrollment with Medicare, Medicaid, and commercial insurance plans.
• Track application statuses and proactively follow up with payers to ensure timely approvals.
• Process provider additions, updates, and terminations with insurance carriers.
• Maintain and update CAQH provider profiles, ensuring all documentation is current and properly attested.
• Monitor expiration dates for licenses, certifications, malpractice coverage, and other required credentials.
• Conduct regular audits to ensure ongoing compliance with regulatory and payer requirements.
• Stay up to date on credentialing standards and insurance guidelines.
• Serve as the primary point of contact for providers regarding credentialing and enrollment inquiries.
• Assist providers with obtaining, renewing, and maintaining required credentials.
• Utilize Monday.com to manage workflows, track credentialing progress, monitor deadlines, and document processes.
• Maintain accurate databases and tracking systems for all credentialing activities.
• Generate reports on credentialing status, enrollment progress, and upcoming expirations.
• Collaborate with cross-functional teams, including Human Resources, Medical Staff Offices, Practice Managers, Revenue Cycle and Billing teams, and insurance representatives.
• Support onboarding of new providers to ensure timely start dates, patient care continuity, and billing readiness.

Requirements

• Minimum of 2 years of experience in provider credentialing and payer enrollment.
• Experience working with Medicare, Medicaid, and commercial insurance credentialing processes.
• Strong knowledge of CAQH, PECOS, and insurance payer portals.
• Proven ability to manage multiple credentialing projects and meet deadlines.
• High level of organization and attention to detail.
• Experience with Monday.com or similar project management tools preferred.
• Strong written and verbal communication skills, with the ability to interact effectively with providers and internal teams.
• Ability to maintain accuracy and confidentiality when handling sensitive provider information.
• Proficiency in Microsoft Office applications, especially Excel and Word.

Location: Brooklyn NY
Salary: $100K

Compensation:
$100,000 per year