Credentialing Specialist

Description

• Put Patients First
• Empower Entrepreneurial Provider and Care Teams
• Operate with Integrity & Excellence
• Be Innovative
• Work As One Team

What You'll Do

• Review, prepare, and submit provider credentialing, enrollment, and recredentialing applications for health plans, government programs, and healthcare organizations
• Manage provider enrollment and maintenance activities within CAQH, PECOS, NPPES, Medicare, Medicaid, and commercial payer portals
• Verify provider qualifications, including education, licensure, certifications, malpractice coverage, and other required documentation
• Maintain accurate credentialing records and monitor renewal timelines to ensure compliance and uninterrupted participation
• Ensure compliance with CMS, Medicare, Medicaid, NCQA, state, and health plan credentialing requirements
• Conduct ongoing exclusion monitoring, including OIG, SAM, and state exclusion screenings
• Research, resolve, and escalate credentialing issues, discrepancies, and payer-related concerns
• Assist with credentialing audits, provider inquiries, and health plan requests
• Partner with providers and internal departments to maintain accurate provider data and timely credentialing completion
• Prepare and provide credentialing status reports and updates to leadership

Qualifications

• High school diploma or equivalent required
• At least 2 years of provider credentialing experience within a physician practice, medical group, IPA, MSO, health plan, or managed care environment
• Experience with CAQH, PECOS, NPPES, Medicare enrollment and revalidation, Medicaid enrollment, and commercial payer credentialing processes
• Strong knowledge of credentialing standards, enrollment procedures, and healthcare regulatory requirements
• Experience working with electronic health records, practice management systems, and credentialing platforms
• Proficiency with Microsoft Office Suite, including Word, Excel, and Outlook
• Strong analytical, organizational, communication, problem-solving, and time management skills
• Exceptional attention to detail and ability to manage sensitive and confidential information

• Credentialing certification through NAMSS, including CPCS (Certified Provider Credentialing Specialist) or CPMSM (Certified Professional Medical Services Management)
• Experience using credentialing software and provider enrollment databases
• Experience with Athenahealth
• Experience within a managed care, IPA, MSO, FQHC, medical group, or health plan environment
• Familiarity with provider network management and healthcare technology systems

Environmental Job Requirements and Working Conditions

• This role follows a remote work structure with periodic travel required to our clinics.
• Must be able to work at a computer for extended periods, review electronic medical records and coding reports, and communicate effectively with providers and staff via phone, video conferencing, email, and Teams chat.
• Ability to attend provider meetings, trainings, and market events as needed.
• The target pay range for this role is $19 - $25 per hour. Actual compensation will be determined based on geographic location, experience, qualifications, internal equity, and other job-related factors.