PROVIDER CREDENTIALING SPECIALIST

Provider Credentialing Specialist

The Provider Credentialing Specialist is responsible for managing provider credentialing, payer enrollment, and network participation activities for TeamCare Medical providers and practice locations. This role serves as the primary liaison between providers, insurance carriers, practice managers, and Finance to ensure timely credentialing, successful payer enrollment, and operational readiness. The Specialist supports the growth of the TeamCare Medical brand by expanding insurance network participation, maintaining strong payer and provider relationships, and coordinating the administrative processes necessary for providers and clinics to deliver and bill for services efficiently.

Job Responsibilities:

Provider Credentialing & Enrollment

• Manage the full lifecycle of provider credentialing, recredentialing, and payer enrollment processes for physicians, nurse practitioners, physician assistants, and other licensed healthcare professionals.
• Prepare, submit, and track credentialing applications with commercial insurance carriers, Medicare, Medicaid, and managed care organizations.
• Complete and submit enrollment and revalidation for Medicare using PECOS system.
• Monitor credentialing and enrollment statuses to ensure timely approvals and minimize delays in provider participation.
• Maintain accurate provider records, licenses, certifications, malpractice insurance documentation, and other credentialing requirements.
• Coordinate provider updates, demographic changes, and revalidation submissions with insurance carriers and regulatory agencies.
• Ensure all credentialing activities comply with regulatory, payer, and organizational requirements.
• Maintain and manage a database tracking expiration and renewal dates for all provider credentials, board certification, malpractice insurance coverage, CAQH re-attestations, and Medicaid and Medicare revalidation dates. Proactively notify providers so renewal processes can begin without disruption.
• Maintain and manage providers' CAQH, including uploading and refreshing supporting documents (licenses, DEA, malpractice COIs, W9s).

Practice & Network Expansion

• Coordinate and manage the enrollment of new TeamCare Medical practice locations with insurance carriers and payer networks.
• Serve as the primary administrative lead for adding clinics, service locations, and providers to payer networks.
• Track payer applications, approvals, contracts, and implementation timelines for new locations.
• Support initiatives that increase patient access and strengthen TeamCare Medical's presence within payer networks.

Payer Relations & Provider Support

• Develop and maintain positive working relationships with insurance representatives, provider relations teams, and payer credentialing departments.
• Serve as the primary contact for credentialing and enrollment inquiries from providers, practice managers, and insurance carriers.
• Proactively resolve credentialing issues, application delays, network participation concerns, and enrollment discrepancies.
• Assist providers and practice leadership in understanding payer requirements and credentialing expectations.
• Promote a professional and responsive experience that supports provider satisfaction and organizational growth.
• Act as the liaison between Finance, Medical Practice Managers, Revenue Cycle, and Medical Operations regarding payer enrollment and provider participation matters.
• Coordinate communication related to billing activation, provider effective dates, claims issues, and payer updates.
• Ensure provider and clinic information is accurately reflected across credentialing, billing, and operational systems.

Compliance & Reporting

• Monitor upcoming credentialing expirations and recredentialing deadlines to ensure continuous participation with payers.
• Maintain credentialing databases, files, and documentation in accordance with organizational policies and regulatory requirements.
• Prepare reports and provide updates to leadership regarding credentialing activities, enrollment timelines, and payer relationships.
• Participate in audits and regulatory reviews as required.
• Recommend process improvements to enhance efficiency, reduce enrollment timelines, and improve provider onboarding.
• Other duties as assigned.

Schedule: 8:30AM – 5:30PM

Weekly Hours: 40

Qualifications:

Education:

• Bachelor's degree in Healthcare Administration, Business Administration, Public Health, or equivalent years of experience.

Experience:

• Minimum of 3 years of experience in healthcare credentialing, provider enrollment, payer relations, medical practice administration, or related healthcare operations.
• Experience credentialing providers with Medicare, Medicaid, and commercial insurance carriers required.
• Experience working with physician practices, clinics, or healthcare organizations preferred.
• Experience managing multiple projects, deadlines, and payer relationships simultaneously.
• Experience with provider enrollment platforms such as CAQH, PECOS, NPPES, and state Medicaid portals.

Physical Requirements

Individuals must be able to sustain certain physical requirements essential to the job. This includes, but is not limited to:

• Standing – Duration of up to 6 hours a day.
• Sitting/Stationary positions – Sedentary position in duration of up to 6-8 hours a day for consecutive hours/periods.
• Lifting/Push/Pull – Up to 50 pounds of equipment, baggage, supplies, and ability to lift patients safely and using OSHA guidelines, etc.
• Bending/Squatting – Must be able to safely bend or squat to care for patients, use medical supplies, etc.
• Stairs/Steps/Walking/Climbing – Must be able to safely maneuver stairs, climb up/down, and walk to access work areas. Position requires the individual to be able to travel, and walk between sites/locations and work areas throughout the day.
• Agility/Fine Motor Skills - Must demonstrate agility and fine motor skills to operate and activate equipment, devices, instruments, and tools (ie. typing, use of medical supplies, equipment, etc.)
• Sight/Visual Requirements – Must be able to visually assess patients, read orders type/write documentation, etc. with accuracy.
• Audio Hearing and Motor Skills (language) Requirements – Must be able to listen attentively and document information from patients, community members, providers, etc., and intake information through audio processing with accuracy. In addition, must be able to speak comfortably and clearly with language motor skills for customers to understand the individual.
• Cognitive Ability – Must be able to demonstrate good decision-making, reasonableness, cognitive ability, rational processing, and analysis to satisfy essential functions of the job.

Disclaimer: Responsibilities and tasks outlined in this job description are not exhaustive and may change as determined by the needs of the company.

We are an affirmative action and equal opportunity employer. All qualified applicants will receive consideration for employment without regard to race, color, religion, sex, disability, age, sexual orientation, gender identity, national origin, veteran status, height, weight, or genetic information. We are committed to providing access, equal opportunity, and reasonable accommodation for individuals with disabilities in employment, its services, programs, and activities.