Credentialing

Job description:

Job Description: Credentialing Specialist

ONSITE - NIGHT SHIFT

Position Overview:
The Credentialing Specialist is responsible for managing the end-to-end credentialing and enrollment process for healthcare providers, ensuring compliance with federal, state, and payer-specific requirements. This role supports accurate provider setup, maintenance, and validation across all relevant systems while maintaining high standards for quality, timeliness, and regulatory adherence.

Key Responsibilities

• Manage full lifecycle provider credentialing, including initial enrollment, re-credentialing, and revalidation for Medicaid, Medicare, and commercial payers.
• Maintain NPI records (Type 1 and Type 2) via NPPES, ensuring accuracy and compliance.
• Prepare, submit, and monitor PECOS applications (CMS-855I, 855B, 855R, and DME) for providers.
• Administer CAQH ProView profiles, ensuring all documentation (COI, licenses, board certifications) is complete, current, and compliant with deadlines.
• Conduct full-cycle credentialing using Availity and payer portals (Anthem, BCBS, Aetna, Cigna, UnitedHealthcare, etc.).
• Ensure adherence to NCQA and URAC accreditation standards throughout the credentialing process.
• Collaborate with internal teams (operations, compliance, HR) and external stakeholders to resolve credentialing issues.
• Monitor key KPI metrics, maintain accurate records, and provide regular status reports to management.
• Identify process improvement opportunities to enhance efficiency, accuracy, and provider satisfaction.

Must-Have Qualifications

• Minimum 3–5 years experience in end-to-end healthcare provider enrollment and payer credentialing.
• Knowledge of Federal and State Enrollment, particularly Medicaid and Medicare.
• Experience managing NPI (Type 1 & 2) using NPPES.
• Strong familiarity with PECOS, including CMS-855I/B/R and DME applications.
• Hands-on experience with CAQH ProView, including initial setup, quarterly re-attestations, and document management.
• Experience using Availity and commercial payer portals.
• Familiarity with NCQA and URAC standards.

Job Type: Full-time

Benefits:

• Company events
• Opportunities for promotion
• Paid training
• Promotion to permanent employee