Enrollment Provider & Credentialing Consultant

• Credential Verification:Verify provider medical licenses, board certifications, DEA registrations, education, and malpractice insurance.
• ​​​​​Network Enrollment: Compile, complete, and submit detailed payer applications, track them to ensure completion, and resolve issues that prevent a provider from gaining "in-network" status with commercial insurance plans. Obtain and manage practice locations and provider rosters. Enroll individual clinicians and group practice in:
  • Tricare, BCBS CareFirst, AETNA, CIGNA, United Healthcare, and other commercial payers as needed
• Database Maintenance: Update and maintain accurate provider profiles in national databases and registries including CAQH and NPPES.
• Tracking & Follow-up: Monitor the status of pending applications with payers to ensure timely network approval and prevent credentialing gaps.  Respond to payer request for additional information.
• Compliance Management: Ensure compliance with payer and regulatory requirements. Track expiration dates for provider licenses, certificates, and insurances to ensure continuous compliance. Maintain enrollment records and approval dates.
• Re-Credentialing & Revalidation Cycle: Proactively update files and renew applications to maintain compliance with changing state, federal (CMS), and accrediting (NCQA/TJC) regulations.  Manage the routine re-credentialing and revalidation processes mandated by insurers and regulatory bodies.
• Issue Resolution: Investigate and resolve enrollment delays, provider data errors, and credentialing-related billing rejections.
• Cross-Department Collaboration: Partner with HR, legal, clinicians, and billing/coding to streamline provider onboarding.
• Contract Coordination
  • Work with payer representatives during the contracting process
  • Ensure contracts are executed and effective dates are recorded
  • Track reimbursement schedules and network participation status

• Education: High school diploma or GED required; bachelor’s degree in healthcare administration or a related field preferred.
• Experience: Minimum of 2–4 years of direct experience in medical credentialing and payer enrollment.
• Systems Proficiency: Hands-on experience using CAQH ProView, NPPES, and electronic medical record (EMR) software.
• Regulatory Knowledge: Deep understanding of NCQA and Joint Commission credentialing guidelines and compliance standards.
• Skill Set: Exceptional attention to detail, strong organizational skills, and excellent written and verbal communication abilities.

• Certification: Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) designation.
• Payer Network: Established relationships or familiarity with regional commercial health plan provider relations departments.

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