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

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Work set up: Work from Home

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Schedule: Monday to Friday | 9:00 PM to 6:00 AM PH Time | Flexible to an extent

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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 creden