Position Summary We are seeking an experienced Senior Provider Credentialing & Reimbursement Specialist to provide corporate-level oversight and support for provider credentialing, medical staff privileging, payer enrollment, and reimbursement activities across our healthcare operations. This position combines two closely related functions: Medical Staff Credentialing & Privileging and Payer Enrollment & Reimbursement. The ideal candidate will have strong experience managing provider data, applications, licenses, other expirable credentials, payer requirements, and regulatory documentation while also possessing the analytical skills necessary to investigate reimbursement issues, resolve payer problems, and identify underpayments. This role requires an exceptionally organized, detail-oriented professional who can independently manage multiple providers, facilities, payers, deadlines, and regulatory requirements. Key Responsibilities Medical Staff Credentialing & Privileging Coordinate initial medical staff appointments and reappointments. Complete and document primary-source verification of provider credentials. Manage provider privilege delineation and approval processes. Maintain complete and accurate medical staff credentialing files. Monitor professional licenses, DEA registrations, board certifications, insurance coverage, and other expirable credentials. Complete National Practitioner Data Bank (NPDB) queries and maintain required documentation. Coordinate credentialing activities through Medical Executive Committee (MEC), medical staff, administration, and governing board approval processes. Coordinate temporary privilege requests when appropriate. Maintain credentialing files in a consistently survey-ready condition. Work closely with hospital administration, medical staff leadership, providers, and corporate leadership to ensure credentialing requirements and deadlines are met. Maintain credentialing processes consistent with applicable regulatory, accreditation, medical staff bylaws, and organizational requirements. Payer Enrollment & Reimbursement Maintain provider information and attestations through CAQH. Manage Medicare provider enrollment, changes, and revalidations through PECOS. Coordinate Medicaid enrollment and revalidation. Complete commercial payer credentialing and enrollment applications. Manage enrollment of individual providers, groups/entities, practice locations, and other required payer relationships. Coordinate EFT, ERA, electronic payer portal access, and related enrollment activities. Track payer applications and verify provider enrollment and effective dates. Maintain accurate records of provider participation and payer enrollment status. Investigate payer-related claim issues associated with credentialing, enrollment, or effective-date problems. Research reimbursement discrepancies and potential payer underpayments. Assist with payer appeals, reconsiderations, and escalations. Work collaboratively with Revenue Cycle Management to resolve reimbursement issues and reduce preventable claim denials. Identify recurring payer or enrollment problems and recommend corrective action. Qualifications Required Minimum of 3-5 years of progressive experience in healthcare credentialing, payer enrollment, provider enrollment, reimbursement, or related healthcare operations. Demonstrated experience with both medical staff credentialing/privileging and payer enrollment. Experience with CAQH, PECOS/Medicare, Medicaid, and commercial payer enrollment. Strong understanding of provider licenses, certifications, credentialing documentation, and expirable credentials. Ability to independently manage multiple provider applications, deadlines, and payer requirements. Strong analytical and problem-solving skills. Exceptional attention to detail and organizational skills. Strong written and verbal communication skills. Ability to work effectively with providers, hospital administrators, medical staff leadership, payers, and revenue cycle personnel. Proficiency with Microsoft Office and electronic credentialing/payer systems. Preferred Experience supporting hospitals, critical access hospitals, rural healthcare organizations, or multi-facility healthcare operations. Experience managing medical staff credentialing through MEC and governing board approval. Working knowledge of CMS and other applicable hospital credentialing requirements. Experience researching underpayments, reimbursement discrepancies, and payer-related claim issues. Experience with payer appeals and escalations. CPCS, CPMSM, or other relevant credentialing certification. Key Competencies Exceptional organization and follow-through Strong attention to detail Provider credentialing expertise Payer enrollment expertise Reimbursement analysis and problem-solving Regulatory awareness Deadline and expirable management Critical thinking Professional communication Ability to manage competing priorities across multiple facilities

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Life insurance Paid time off Vision insurance

Work Location:

In person