Credentialing Specialist

Job Overview

Our client is looking for an experienced and detail-oriented Credentialing Specialist to manage provider credentialing, payer enrollment, insurance contracting, and provider record maintenance. The role will serve as a primary resource for credentialing activities and will ensure providers remain properly enrolled, credentialed, and compliant with applicable insurance payers.

The ideal candidate has hands-on experience independently managing the provider credentialing process from application through approval and ongoing maintenance, with strong organizational skills and attention to detail.

Job Details

• Work set up: Work from Home
• Schedule: Monday to Friday | 9:00 PM to 6:00 AM PH Time | Flexible to an extent
• Holiday: Follows U.S. holidays

Responsibilities:

Provider Credentialing & Enrollment

• Manage all aspects of 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.
• Update and add new providers, supervising physicians, and practice locations to payer contracts as required.
• Maintain provider credentialing information in CAQH, NPPES, PECOS, state licensing boards, DEA registrations, malpractice coverage, and other applicable registries.
• Monitor provider credentialing expiration dates and proactively complete renewals and revalidations to prevent lapses in provider participation.
• Coordinate credentialing and payer enrollment activities for newly hired providers.
• Follow up with insurance companies and credentialing organizations regarding application status, outstanding documentation, and enrollment issues.
• Research payer-specific credentialing requirements and communicate requirements and updates to leadership.
• Maintain accurate and organized credentialing files, documentation, and tracking systems.
• Assist with adding new practice locations and services to payer contracts as the organization grows.
• Maintain accurate provider information within AthenaOne and other internal systems.
• Assist with credentialing audits and respond to payer requests for additional documentation.
• Identify and communicate potential credentialing or payer enrollment issues that could affect provider participation.

Insurance Contracting & Payer Relations

• Review and maintain payer contracts and provider participation information.
• Serve as the primary point of contact for credentialing-related communication with insurance companies, credentialing organizations, and provider enrollment representatives.
• Maintain professional relationships with payer representatives and follow up consistently on outstanding credentialing matters.
• Work collaboratively with providers and leadership to obtain required credentialing documentation.
• Assist leadership with research related to new insurance networks and payer participation opportunities.
• Assist with adding providers and locations to existing payer contracts.
• Monitor payer requirements and communicate changes that may affect provider enrollment or participation.

Provider Onboarding

• Coordinate credentialing and payer enrollment activities for newly hired providers.
• Obtain and organize all required provider documentation for credentialing and enrollment.
• Track the status of each provider throughout the credentialing process and communicate updates to leadership.
• Ensure providers are properly enrolled with applicable payers prior to providing services that require insurance participation.
• Maintain complete and accurate provider credentialing files throughout employment.

Quality Care

• Maintain the strictest confidentiality and adhere to all HIPAA guidelines and regulations.
• Maintain a broad knowledge of provider credentialing requirements, insurance plans, payer regulations, and applicable Federal and State requirements.
• Ensure all credentialing activities are conducted in accordance with Federal, State, and payer regulations, guidelines, and requirements.
• Recognize and support patients' rights and responsibilities in the performance of job duties while respecting their privacy and confidentiality.
• Maintain accurate and timely documentation in accordance with company policies and payer requirements.
• Be prepared to undertake additional credentialing, payer relations, and administrative projects as assigned, demonstrating flexibility and a team-oriented mindset.

Qualifications

• 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.