Payer Credentialing Specialist

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.