Provider Enrollment and Credentialing

Pay: Base Wage starting at $22; increased based on experience

Incentive Eligible Position: Yes

Summary of Duties:

The Provider Enrollment Specialist and Medical Staff Credentialing is an integral role within the Nevada Regional Medical Center Quality Department. This position is responsible for managing the end-to-end credentialing, re-credentialing, privileging, and payer enrollment processes for physicians, advanced practice providers (APPs), and allied health professionals.

Operating within NRMC's rigorous quality framework (aligned with CIHQ and state/federal regulatory standards), this role ensures that all medical staff members maintain active, compliant credentials and active billing/network statuses, directly protecting patient safety and supporting hospital financial operations.

Essential Functions:

1. Medical Staff Credentialing & Privileging

• Manage the initial appointment, reappointment, and expedited credentialing processes for all members of the Medical Staff and Allied Health Professionals in accordance with NRMC bylaws, rules, regulations, and accrediting standards.
• Conduct thorough primary-source verification (PSV) of licensure, education, training, board certification, work history, malpractice history, and peer references.
• Process clinical privilege requests, ensuring alignment with training, competency, and defined hospital scope-of-practice guidelines.
• Prepare comprehensive credentialing files and summary packets for presentation to the Medical Staff Credentials Committee and the Board of Directors.
• Maintain absolute confidentiality regarding all peer review and provider credentialing records.

2. Provider Enrollment (Payer Credentialing)

• Coordinate and manage provider enrollment and contract setup with Medicare, Missouri Medicaid (MO HealthNet), commercial insurance payers, and managed care organizations.
• Maintain and actively manage provider profiles within the Council for Affordable Quality Healthcare (CAQH) ProView system, NPPES (NPI registry), and PECOS, ensuring regular re-attestations and data accuracy.
• Track the lifecycle of all enrollment applications from initial submission to active network status, proactively resolving discrepancies or information requests from payers to prevent revenue cycle bottlenecks.
• Coordinate closely with the Patient Financial Services and Billing departments to ensure seamless transitions for newly onboarded providers.

3. Compliance, Tracking, and Reporting

• Monitor expiration dates for professional licenses, DEA registrations, controlled substance certificates, malpractice insurance (COIs), and life support certifications, executing tracking workflows well in advance of deadlines.
• Ensure organizational compliance with regulatory requirements, including CMS conditions of participation, CIHQ accreditation standards, and state regulations.
• Assist with internal audits, regulatory surveys, and quality reviews related to medical staff governance and provider credentialing data.
• Promptly report any changes in provider status (e.g., sanction flags, loss or restriction of privileges, license actions) to appropriate administrative leadership, credentialing committees, and contracted health plans.

The above statements are intended to describe the general nature and level of work performed by employees within this classification. It is not designed to contain or be interpreted as a comprehensive inventory of all duties, responsibilities and qualifications required of employees assigned to this job.

Skills Abilities:

1. Ability to communicate clearly and effectively with all levels

2. Ability to complete competency CPR and First Aid

3. Ability to prioritize and complete multiple tasks simultaneously.

4. Effective oral and written communication skills.

5. Exceptional attention to detail and high degree of accuracy with sensitive data.

6. Proficiency with credentialing software platforms, CAQH, PECOS, and electronic medical record / office applications.

7. Excellent written and verbal communication skills, with the ability to interface professionally with physicians, executive leadership, and external agency representatives.

8. Strong time-management capabilities with the ability to multitask effectively in a fast-paced healthcare environment.

Working Conditions:

1. Exposure to distressed patients, families or visitors.

2. Possible exposure to inside environmental conditions.

Physical Demands:

1. Requires standing, sitting or walking for up to 12 hours or longer per workday.

2. The ability to lift up to 50 lbs.

Qualifications:

1. High school diploma or equivalent required; Associate's or Bachelor's degree in healthcare administration, business, or a related field is strongly preferred.

2. Minimum of 2-3 years of direct experience in medical staff credentialing, privileging, and/or provider enrollment within a hospital, healthcare system, or managed care environment.

3. Strong working knowledge of NCQA, CMS, and CIHQ accreditation standards.

Preferred Qualifications:

1. Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) through NAMSS is highly preferred (or a commitment to obtaining certification within an agreed timeframe).