Credentialing Specialist

Credentialing Specialist - Payer Enrollment & Health Plan Experience

Full-Time Contract • Remote (United States) • US Citizenship Required

POSITION OVERVIEW:

Experienced Credentialing Specialist sought to direct end-to-end provider enrollment and credentialing operations across commercial and government health plans. This role demands deep expertise in payer enrollment workflows, regulatory compliance, and multi-payer coordination, with the ability to manage competing priorities in a fully remote, fast-paced healthcare environment. The ideal candidate brings demonstrated success navigating CMS, NCQA, and state/federal compliance requirements while driving timely, audit-ready credentialing outcomes.

KEY RESPONSIBILITIES:

Payer Enrollment

• Direct end-to-end payer enrollment for providers across commercial, Medicare, and Medicaid health plans, ensuring accurate and timely application submission.
• Prepare, complete, and submit enrollment applications via CAQH ProView, PECOS, NPPES, and payer-specific platforms, managing all documentation requirements.
• Track application pipelines and execute proactive follow-up with payers to accelerate processing timelines and secure approvals.
• Coordinate with billing and revenue cycle teams to align enrollment effective dates with claims submission readiness.

Provider Credentialing & Revalidation

• Manage provider re-credentialing and revalidation cycles in compliance with NCQA, CMS, and applicable state/federal regulatory standards.
• Verify provider credentials, including licenses, board certifications, malpractice insurance, education, and work history, through primary source verification.
• Maintain audit-ready credentialing files, provider records, and CAQH profiles with complete and current documentation.
• Resolve credentialing and enrollment discrepancies through cross-functional coordination with providers, health plans, and internal operational teams.

Compliance & Provider Onboarding

• Ensure continuous compliance with CMS, NCQA, and state/federal healthcare regulations across all credentialing and enrollment activities.
• Generate credentialing status reports and enrollment metrics to inform leadership decision-making and operational planning.
• Support provider onboarding and contracting workflows, facilitating smooth transitions from credentialing approval to active participation.

REQUIRED QUALIFICATIONS:

• 3–5 years of hands-on experience in healthcare credentialing and payer enrollment within a provider group, health system, or managed care setting.
• Demonstrated proficiency with CAQH ProView, PECOS, NPPES, and commercial/government payer enrollment portals.
• Working knowledge of CMS, NCQA, and applicable state/federal compliance frameworks governing provider credentialing.
• Exceptional organizational skills with the ability to manage multiple concurrent enrollment files and credentialing deadlines.
• Strong written and verbal communication skills for effective engagement with providers, payers, and cross-functional stakeholders.
• U.S. Citizenship required.

PREFERRED QUALIFICATIONS;

• Prior experience in healthcare staffing, managed care organizations, or multi-specialty hospital systems.
• Proficiency with credentialing management platforms such as Cactus, Symplr, MD Staff, or equivalent solutions.
• Working knowledge of provider contracting processes and health plan network onboarding requirements.
• Certified Provider Credentialing Specialist (CPCS) or equivalent professional credential preferred.