Credentialing Specialist

Job Summary
The Credentialer is responsible for managing the credentialing, recredentialing, and insurance enrollment process for healthcare providers. This role involves coordinating with providers, insurance companies, and other stakeholders to ensure accurate documentation, timely submissions, and compliance with payer requirements.

Key Responsibilities

• Manage initial credentialing, recredentialing, and provider enrollment with commercial and government insurance payers.


• Collect, verify, and maintain provider credentials, including licenses, certifications, NPI, CAQH, malpractice insurance, and other required documents.


• Complete and submit insurance enrollment and credentialing applications accurately and within required timelines.


• Monitor application status, follow up with insurance payers, and resolve missing information or enrollment issues.


• Communicate with providers and internal teams regarding credentialing requirements, documentation, and application status.


• Maintain accurate and up-to-date provider credentialing records and track expiration dates.


• Coordinate with insurance representatives and payer portals to obtain updates, approvals, and participation information.


• Ensure compliance with payer, regulatory, and organizational credentialing requirements.


• Prepare regular reports on credentialing status, pending applications, expirations, and outstanding requirements.


• Handle calls and email correspondence with providers, insurance companies, and other stakeholders as needed.

Preferred Qualifications

• Experience in healthcare credentialing, provider enrollment, medical billing, or healthcare administration.


• Familiarity with CAQH, NPI, PECOS, Medicare, Medicaid, and commercial insurance payers.


• 
  Strong attention to detail and documentation skills.


• Excellent follow-up, organization, and communication skills.


• Comfortable making phone calls and coordinating with insurance representatives.


• Ability to manage multiple providers, applications, and deadlines simultaneously.