Payor Credentialing Specialist

What You'll Be Doing:

The Payor Credentialing Specialist performs duties associated with payor enrollment, credentialing, re-credentialing, and privileging network providers.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Coordinate the credentialing, recredentialing, and provider enrollment process for physicians, advanced practice providers, and allied health professionals.
• Complete, review, and submit credentialing and enrollment applications to Medicare, Medicaid, commercial insurance carriers, and managed care organizations.
• Monitor application status, follow up with payors, and resolve deficiencies to ensure timely provider enrollment.
• Verify provider credentials, including licensure, education, training, certifications, work history, malpractice coverage, and other required documentation.
• Maintain provider records in credentialing databases: MD Staff, CAQH, PECOS, NPPES, and other applicable systems, enabling tracking of credential expiration dates and maintenance of audit-ready files.
• Coordinate with providers and internal departments to obtain required documentation and respond to requests from payors for additional information.
• Research and resolve credentialing and enrollment issues affecting provider participation and reimbursement.
• Generate credentialing reports, maintain enrollment status reports, and support internal and external audits.
• Ensure compliance with federal and state regulations, accreditation standards, HIPAA, and organizational policies; communicate credentialing status updates to leadership and providers.
• Participate in process improvement initiatives.
• Willingness to work occasional nights and weekends with up to 25% of travel required.

Education:

• High School or GED - Required
• Bachelors Degree in Business, healthcare or any related field of study. Equivalent years of experience (in addition to requirement) may be substituted for degree. (Preferred)