Credentialing and Enrollment Specialist

Position Summary

The Credentialing & Enrollment Specialist is responsible for coordinating provider credentialing, recredentialing, and payer enrollment activities to ensure practitioners are properly credentialed, enrolled, and compliant with regulatory, accreditation, payer, and organizational requirements. This position works closely with providers, payers, and internal stakeholders to support timely onboarding and ongoing maintenance of provider records.

Essential Duties and Responsibilities

• Credentialing
• Coordinate initial credentialing and recredentialing for physicians, advanced practice providers, and allied health professionals.
• Gather, verify, and maintain required credentialing documentation, including licenses, DEA registrations, board certifications, malpractice insurance, and CVs.
• Perform primary source verification in accordance with payer and regulatory requirements.
• Monitor expiration dates and ensure timely renewal of licenses, certifications, and other required documents.
• Maintain accurate and audit-ready provider credentialing files.
• Provider Enrollment
• Prepare and submit provider enrollment applications for Medicare, Medicaid, commercial payers, Workers' Compensation, and other government programs.
• Track application status and follow up with payers to resolve issues and expedite approvals.
• Maintain provider records and updates within payer portals and enrollment systems.
• Assist with provider onboarding, location additions, and provider demographic updates.
• Compliance & Data Management
• Maintain accurate provider data within credentialing databases and systems.
• Ensure compliance with payer, state, federal, and organizational credentialing standards.
• Support credentialing audits and accreditation activities.
• Assist with provider roster maintenance and directory accuracy.
• Communication
• Serve as a primary point of contact for providers regarding credentialing and enrollment requirements.
• Communicate professionally with providers, payer representatives, practice leadership, and internal departments.
• Provide timely status updates and escalate issues when necessary.

Qualifications

• High School Diploma or equivalent required; Associate's or Bachelor's degree preferred.
• 1-3 years of healthcare credentialing, enrollment, medical staff services, or related experience preferred.
• Knowledge of credentialing, recredentialing, CAQH, Medicare, Medicaid, and commercial payer enrollment processes.
• Strong organizational, analytical, and problem-solving skills.
• Excellent communication and customer service abilities.
• Proficiency with Microsoft Office, particularly Excel, Word, and Outlook.
• Ability to manage multiple priorities while maintaining a high degree of accuracy and confidentiality.

Success Factors

• Timely completion of provider credentialing and enrollment activities.
• Accurate maintenance of provider records and credentialing files.
• Compliance with regulatory and payer requirements.
• Effective collaboration with providers, payers, and internal teams.
• Ability to support organizational growth through efficient provider onboarding and enrollment processes.