Credentialing Specialist
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Job Description
Credentialing Specialist managing U.S. healthcare provider credentialing, payer enrollment, and insurance contracting. Maintaining compliant provider records and supporting onboarding for a medical organization.
Responsibilities:
- Manage initial provider credentialing and recredentialing with commercial insurance companies, Medicare, Medicaid, and other contracted payers
- Complete and track payer enrollment applications from submission through approval
- Add and update providers, supervising physicians, practice locations, and services in payer contracts
- Maintain credentialing information in CAQH, NPPES, PECOS, state licensing boards, DEA registrations, malpractice coverage, AthenaOne, and other systems
- Monitor expiration dates and complete renewals, revalidations, and credentialing maintenance to prevent participation lapses
- Coordinate credentialing and payer enrollment for newly hired providers
- Follow up with insurance companies and credentialing organizations regarding application status, documentation, and enrollment issues
- Research payer-specific requirements and communicate updates to leadership
- Maintain accurate credentialing files, documentation, and tracking systems
- Assist with credentialing audits and payer requests for additional documentation
- Identify and communicate issues that could affect provider participation
- Review and maintain payer contracts and provider participation information
- Serve as primary contact for credentialing-related communication with payers and enrollment representatives
- Maintain professional payer relationships and follow up on outstanding matters
- Collaborate with providers and leadership to obtain required documentation
- Assist leadership with research on new insurance networks and payer participation opportunities
- Ensure providers are enrolled with applicable payers before providing services requiring insurance participation
- Maintain confidentiality and comply with HIPAA, Federal, State, and payer requirements
- Recognize and support patients' rights and responsibilities while respecting privacy and confidentiality
- Undertake additional credentialing, payer relations, and administrative projects as assigned
Requirements:
- High school diploma or General Education Degree (GED) equivalent
- Minimum of 3 years of dedicated medical provider credentialing experience required
- Demonstrated experience independently managing provider credentialing from application through payer approval and ongoing maintenance
- Hands-on experience with CAQH, NPPES, PECOS, Medicare and Medicaid enrollment, commercial insurance credentialing and contracting, state licensing, and DEA registrations
- Experience managing provider recredentialing, payer revalidations, and credentialing renewals
- Experience communicating directly with commercial insurance companies and payer enrollment representatives
- Behavioral health and/or addiction medicine credentialing experience strongly preferred
- Experience with AthenaOne or other healthcare EMR/practice management systems preferred
- Ability to independently manage multiple providers, payers, applications, deadlines, and credentialing requirements
- Excellent verbal and written communication skills with the ability to work effectively with providers, insurance representatives, credentialing organizations, and internal staff
- Strong organizational skills with exceptional attention to detail
- Self-directed, dependable, and able to work independently while managing multiple priorities and deadlines
- Proficiency in Microsoft Office, including Outlook, Word, and Excel
Benefits:
- Work from Home
- Monday to Friday schedule
- Flexible schedule to an extent
- U.S. holidays observed
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