Credentialing Specialist

Position Summary

The Credentialing Specialist is responsible for ensuring that all providers are properly credentialed, revalidated, and enrolled with federal, state, and commercial payers. This role manages the complete lifecycle of credentialing and payer enrollment, maintains accurate records, and ensures compliance with regulatory and payer requirements to prevent revenue disruption.

Key Responsibilities

Provider Enrollment & Credentialing

• Prepare, submit, and track initial credentialing, recredentialing, and revalidation applications for all providers and locations.
• Manage Medicare (PECOS/855), Medicaid, and commercial payer enrollments, including PTAN/NPI linkages and location changes.
• Maintain provider CAQH profiles, ensuring all information is current and attested on schedule.
• Coordinate with providers to collect required documents (licenses, DEA/CSA, CV, board certifications, malpractice, etc.).

Payer Communication & Follow-Up

• Monitor application status with payers; follow up regularly to ensure timely approvals.
• Serve as primary contact between payers, vendors, and internal departments regarding credentialing matters.
• Resolve discrepancies or requests for additional information from payers.

Compliance & Documentation

• Ensure provider and organizational credentialing is compliant with federal/state regulations, accreditation requirements, and payer policies.
• Maintain confidential and organized digital credentialing files for each provider and location.
• Track expiration dates for licenses, certifications, DEA, malpractice coverage, and renewals.

Data Management & Reporting

• Maintain accurate tracking logs or credentialing software (e.g., Modio, symplr, Credstream).
• Generate regular reports on application status, expirables, and upcoming renewals.
• Assist leadership in audits, payer reviews, and compliance inquiries.

Operational Support

• Work closely with Revenue Cycle, Billing, HR, Compliance, and Operations teams to ensure credentialing is aligned with onboarding, scheduling, and billing workflows.
• Notify internal teams immediately when providers are fully credentialed to avoid billing delays.
• Support onboarding of new providers by guiding them through required credentialing steps.

Qualifications

• High school diploma required; associate or bachelor’s degree preferred.
• Minimum 2–3 years credentialing or payer enrollment experience (preferably in a physician practice or multi-specialty group).
• Strong understanding of Medicare/Medicaid enrollment, commercial payer credentialing, NPI/PECOS, CAQH, and revalidation processes.
• Experience with credentialing software is preferred.
• Excellent attention to detail and strong organizational skills.
• Ability to work independently, manage multiple tasks, and meet strict deadlines.
• Strong written and verbal communication skills.
• Knowledge of healthcare compliance standards.

Core Competencies

• High accuracy and attention to detail
• Strong follow-up skills
• Ability to prioritize in a deadline-driven environment
• Professional communication with payers and providers
• Confidentiality and discretion
• Problem-solving and persistence
• Ability to work cross-functionally across departments