Job Summary:

The Payer Credentialing Specialist is responsible for coordinating and maintaining the credentialing and enrollment of providers with Medicare, Medicaid, commercial insurance companies, managed care organizations and other third-party payers. This position ensures provider applications, recredentialing, demographic updates, payer enrollments, and supporting documentation are completed accurately and within required timelines. The specialist serves as a key resource for preventing claim denials and revenue loss associated with provider enrollment, credentialing, contracting and payer record inaccuracies.

Essential Duties and Responsibilities:

Complete initial and recredentialing applications for physicians, advanced practice providers, facilities, and other eligible healthcare professionals. Submit provider enrollment applications to Medicare, Medicaid, commercial payers, and managed care organizations. Maintain accurate provider information within payer portals and enrollment systems Track applications from submission through approval. Monitor payer enrollment status and follow up on pending applications. Ensure providers are appropriately enrolled with the applicable payer before services are rendered when required. Maintain a centralized credentialing calendar and ensure recredentialing requirements are completed timely. Monitor expiration dates for licenses, certifications, malpractice insurance, DEA registrations and other required credentials. Complete provider demographic and practice location updates.

Process changes related to:

Name Address Tax Identification Number NPI Specialty Practice Location Group Affiliation Provider Status EFT/ERA information Ensure payer record remain current and accurate. Maintain access to payer enrollment and credentialing portals. Research payer-specific enrollment requirements. Submit required documentation according to payer guidelines. Monitor payer correspondence and requests for additional information. Respond to payer requests within established deadlines. Maintain documentation of submissions, approvals, and communications. All other duties assigned.

Performance Expectations:

Complete credentialing and enrollment applications accurately and timely. Maintain 100% compliance with established recredentialing deadlines. Proactively monitor provider credentials and enrollment status. Minimize claim denials related to provider enrollment. Maintain accurate payer records. Respond promptly to payer requests. Maintain complete and organized credentialing documentation. Communicate enrollment issues before they impact billing or reimbursement. Demonstrate strong attention to detail and ownership of assigned providers. Maintain professional relationships with payers and internal departments.

Qualifications:

Education/Skills:

High school diploma or equivalent required Associate's or bachelor's degree in healthcare administration, business or related field preferred 2 to 4 years of healthcare credentialing, provider enrollment, payer relations, or revenue cycle experience preferred Experience with Medicare and Medicaid enrollment preferred Experience working with commercial payer credentialing and enrollment processes preferred Experience with CAQH and payer enrollment portals preferred Knowledge of healthcare provider credentialing and enrollment processes Familiarity with Medicare, Medicaid, and commercial payer requirements Understanding of NPI, taxonomy, CAQH, EFT/ERA and provider enrollment terminology Strong organizational and time-management skills Excellent attention to detail Strong written and verbal communication skills Ability to manage multiple providers, payers, and deadlines simultaneously Strong problem-solving and follow-up skills Proficiency with Microsoft Office, payer portals, and healthcare information systems

Work Location:

Onsite in-office at the main location.