Job Summary
We are seeking a highly organized and detail-oriented Credentialing Specialist to oversee and manage all aspects of provider and facility credentialing. This individual will be responsible for coordinating enrollment, credentialing, and re-credentialing activities for providers and facilities with commercial payers, Medicare, Medicaid, IPAs, and hospitals.
The ideal candidate is proactive, technical, adaptable, and capable of managing multiple projects while maintaining accuracy and compliance. This role requires strong communication skills, the ability to work independently, and a commitment to maintaining efficient credentialing operations from start to finish.
Essential Duties and Responsibilities
- Conduct audits of contracted insurance networks to verify provider and facility credentialing status.
- Obtain all required credentialing documentation and provider logins in a timely manner.
- Complete and submit provider enrollment and credentialing applications for Medicare, Medicaid, IPAs, commercial health plans, and hospitals.
- Maintain accurate credentialing records and monitor application progress using credentialing tracking tools and databases.
- Manage communication with providers regarding credentialing documentation and application status.
- Track provider licenses, certifications, malpractice insurance, and other expirables.
- Maintain and update provider CAQH profiles, including attestations and document uploads.
- Ensure compliance with all applicable federal, state, accreditation, and payer requirements.
- Verify provider documentation and maintain organized electronic credentialing files.
- Coordinate provider enrollment requirements based on individual payer guidelines.
- Conduct periodic audits of credentialing forms and payer processes for accuracy and compliance.
- Assist in developing and improving credentialing workflows, systems, and processes.
- Organize, label, and maintain credentialing applications and supporting documentation.
- Follow up on pending applications with payers and communicate updates to providers via phone and email.
- Maintain credentialing databases and ensure all provider demographic information is current and accurate.
- Assist with provider contract coordination and negotiations as needed.
- Audit payer directories and portals to maintain accurate provider listings and demographic information.
- Run monthly OIG exclusion checks for all providers and escalate concerns immediately.
- Support onboarding activities for new providers related to credentialing and enrollment.
- Prepare reports and maintain records related to credentialing activities.
- Exercise professionalism, discretion, and confidentiality in all internal and external interactions.
Qualifications and Skills
- Prior credentialing experience in a healthcare environment required.
- Strong knowledge of provider enrollment, credentialing, and re-credentialing processes.
- Excellent interpersonal and communication skills with the ability to work effectively with physicians, providers, executives, and staff.
- Ability to manage multiple projects, deadlines, and priorities in a fast-paced environment.
- Strong organizational skills and exceptional attention to detail.
- Ability to analyze complex application issues and provide effective solutions.
- Proficient in Microsoft Office Suite and credentialing software/databases.
- Knowledge of accreditation standards and payer requirements preferred.
- Professional demeanor and ability to work independently and collaboratively.
Education
- Bachelor’s degree in Healthcare Administration, Business Administration, or a related field preferred.
Job Type: Full-time
Pay: From $173.13 per hour
Work Location: Remote
