Credentialing Specialist

• Manage the full lifecycle of provider credentialing, recredentialing, privileging, and payer enrollment processes for physicians and advanced practice providers.
• Ensure timely submission and follow-up of applications with commercial payers, Medicare, Medicaid, hospitals, and ancillary facilities.
• Monitor credentialing expirables including licenses, DEA registrations, board certifications, malpractice insurance, and CME requirements.
• Maintain accurate provider records within credentialing databases and CAQH profiles.
• Oversee provider onboarding timelines to ensure providers are credentialed and enrolled prior to start dates whenever possible.
• Coordinate provider privileging and medical staff applications with hospitals and surgery centers.

• Ensure compliance with NCQA, CMS, state, and payer credentialing standards.
• Develop and maintain credentialing policies, procedures, and audit readiness documentation.
• Conduct routine audits of provider files and credentialing records.
• Monitor regulatory changes impacting credentialing and provider enrollment.

• Establish and track credentialing KPIs such as enrollment turnaround time, application aging, and provider readiness timelines.
• Collaborate with recruiting and onboarding teams to improve provider start-date readiness.
• Partner with revenue cycle leadership to minimize delays in billing due to credentialing issues.
• Identify workflow inefficiencies and implement process improvements and automation opportunities.

• Serve as the primary escalation point for credentialing-related issues.
• Communicate credentialing status updates regularly to operational and executive leadership.
• Support provider acquisition, expansion, and de novo clinic initiatives through credentialing coordination.
• Build strong working relationships with payers, hospital systems, and third-party credentialing partners.

• Bachelor’s degree or equivalent experience preferred.
• 5+ years of provider credentialing experience in healthcare.
• 2+ years of leadership or supervisory experience.
• Strong understanding of payer enrollment, privileging, and credentialing regulations.
• Experience with Medicare, Medicaid, and commercial payer enrollment processes.
• Proficiency with credentialing software platforms, CAQH, PECOS, and provider databases.
• Strong organizational skills with exceptional attention to detail.
• Ability to manage multiple priorities and deadlines in a fast-paced environment.

• CPCS (Certified Provider Credentialing Specialist) or CPMSM certification.
• Experience in multi-site physician practice management or healthcare roll-up environments.
• Familiarity with pain management, surgical, or specialty practice operations.
• Experience leading credentialing process optimization initiatives.

• Operational leadership
• Process improvement mindset
• Attention to detail
• Problem-solving and critical thinking
• Strong communication and stakeholder management
• Compliance orientation
• Ability to work cross-functionally

• Reduction in credentialing turnaround times
• Percentage of providers credentialed before start date
• Clean application submission rate
• Reduction in payer enrollment delays impacting billing
• Compliance audit readiness and accuracy
• Provider onboarding satisfaction

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