Provider Credentialing Specialist

The Provider Credentialing Specialist is responsible for all aspects of provider enrollment, credentialing, recredentialing, and privileging processes for employed practitioners. This includes maintaining accurate provider data in credentialing databases, hospital databases, ensuring timely submission and renewal of required documentation, and supporting compliance standards.  The Provider Credentialing Specialist works closely with providers, payers, and internal departments to ensure practitioners are appropriately credentialed and enrolled to support timely patient access and reimbursement.

ESSENTIAL DUTIES AND RESPONSIBILITIES:

• Coordinates initial credentialing and recredentialing for physicians, physician assistants, nurse practitioners, and advanced practice providers across Medicare, Commercial Insurers, and delegated payers.


• Manages onboarding process for physicians and advanced practice providers, ensuring seamless transition for full integration into the Practice.


• Develops Physician internal and external On-Call schedules to ensure appropriate coverage at all times.


• Obtains and maintains NPI numbers utilizing PECOS, Availity, CAQH, and NPPES websites.


• Maintains timely and accurate data entry in credentialing databases and payer portals; updates provider rosters and profiles as needed.


• Processes facility privilege applications and reappointments of privileges.


• Submits and updates provider information in CAQH Proview system as required by participating health plans.


• Assists with issue resolution in communication with payers regarding credentialing/enrollment status and delays.


• Participates in internal audits, special projects, weekly report delivery, and process improvements as directed.


• Performs other duties as assigned by Practice Manager.

REQUIRED QUALIFICATIONS AND ABILITIES:

• Minimum High School Diploma or equivalent.


• Degree in Healthcare Administration, business, or a related field a plus but not required


• Certified Provider Credentialing Specialist (CPCS or CPES) preferred


• Minimum 2 years’ experience in provider credentialing or enrollment, preferably in a healthcare, medical group, or managed care environment.


• Proficiency in Microsoft Office suite, AllScripts PM/EHR, Credentialling software, and payer enrollment systems.


• Strong attention to detail, organization, and ability to manage multiple tasks and deadlines.


• Effective verbal and written communication skills, especially in provider-facing interactions.


• Ability to handle sensitive data with a high level of confidentiality and accuracy.


• Experience using CAQH, AppCentral, Parallon and 3-Won platforms preferred.


• Basic understanding of medical terminology and healthcare regulations.


• Able to effectively understand, follow, and communicate oral and written instructions in English. Must read, write, and speak English fluently to ensure clear work-related communication and patient safety.

PHYSICAL REQUIREMENTS:

• Able to spend prolonged periods sitting at a desk while working on a computer, standing, and walking.

INCLUSIVE, EQUAL OPPORTUNITY EMPLOYER