Credentialing Specialist

Job Description

Job Description

Description:

Specific Role:

Credentialing Specialist

Reports To:

Revenue Cycle Manager

Job Description:

The Medical Credentialing Specialist supports Foothills Neurology’s Billing and Finance Department by managing all aspects of provider credentialing, payer enrollment, and re-credentialing. This position ensures that all physicians, nurse practitioners, 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, and able to manage multiple credentialing timelines while maintaining thorough documentation and communication across departments.

Key Responsibilities

• 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, board certifications, malpractice insurance, and CAQH profiles.
• Track expirations, renewals, and re-attestation deadlines to ensure compliance with payer and regulatory requirements.
• Conduct primary source verification and maintain accurate digital credentialing files.
• Communicate directly with payers, providers, and internal departments to resolve application or 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.
• Support audits, compliance checks, and payer correspondence as needed.
• Stay updated on changes in managed care regulations and medical terminology to ensure best practices are followed.

Required Education:

• Education: High school diploma or equivalent required; Associate’s or Bachelor’s degree preferred.

Required Experience:

• 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, 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.
• 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).

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.