Credentialing Specialist

Job Overview Our client is looking for an experienced and detail-oriented Credentialing Specialist to manage provider credentialing, payer enrollment, insurance contracting, and provider record maintenance. The role will serve as a primary resource for credentialing activities and will ensure providers remain properly enrolled, credentialed, and compliant with applicable insurance payers. The ideal candidate has hands-on experience independently managing the provider credentialing process from application through approval and ongoing maintenance, with strong organizational skills and attention to detail. Job Details - Work set up:Work from Home - Schedule: Monday to Friday | 9:00 PM to 6:00 AM PH Time | Flexible to an extent - Holiday: Follows U.S. holidays Responsibilities: Provider Credentialing & Enrollment - Manage all aspects of initial provider credentialing and recredentialing with commercial insurance companies, Medicare, Medicaid, and other contracted payers. - Complete and track payer enrollment applications from submission through approval. - Update and add new providers, supervising physicians, and practice locations to payer contracts as required. - Maintain provider credentialing information in CAQH, NPPES, PECOS, state licensing boards, DEA registrations, malpractice coverage, and other applicable registries. - Monitor provider credentialing expiration dates and proactively complete renewals and revalidations to prevent lapses in provider participation. - Coordinate credentialing and payer enrollment activities for newly hired providers. - Follow up with insurance companies and credentialing organizations regarding application status, outstanding documentation, and enrollment issues. - Research payer-specific credentialing requirements and communicate requirements and updates to leadership. - Maintain accurate and organized credentialing files, documentation, and tracking systems. - Assist with adding new practice locations and services to payer contracts as the organization grows. - Maintain accurate provider information within AthenaOne and other internal systems. - Assist with credentialing audits and respond to payer requests for additional documentation. - Identify and communicate potential credentialing or payer enrollment issues that could affect provider participation. Insurance Contracting & Payer Relations - Review and maintain payer contracts and provider participation information. - Serve as the primary point of contact for credentialing-related communication with insurance companies, credentialing organizations, and provider enrollment representatives. - Maintain professional relationships with payer representatives and follow up consistently on outstanding credentialing matters. - Work collaboratively with providers and leadership to obtain required credentialing documentation. - Assist leadership with research related to new insurance networks and payer participation opportunities. - Assist with adding providers and locations to existing payer contracts. - Monitor payer requirements and communicate changes that may affect provider enrollment or participation. Provider Onboarding - Coordinate credentialing and payer enrollment activities for newly hired providers. - Obtain and organize all required provider documentation for credentialing and enrollment. - Track the status of each provider throughout the credentialing process and communicate updates to leadership. - Ensure providers are properly enrolled with applicable payers prior to providing services that require insurance participation. - Maintain complete and accurate provider credentialing files throughout employment. Quality Care - Maintain the strictest confidentiality and adhere to all HIPAA guidelines and regulations. - Maintain a broad knowledge of provider credentialing requirements, insurance plans, payer regulations, and applicable Federal and State requirements. - Ensure all credentialing activities are conducted in accordance with Federal, State, and payer regulations, guidelines, and requirements. - Recognize and support patients' rights and responsibilities in the performance of job duties while respecting their privacy and confidentiality. - Maintain accurate and timely documentation in accordance with company policies and payer requirements. - Be prepared to undertake additional credentialing, payer relations, and administrative projects as assigned, demonstrating flexibility and a team-oriented mindset. Qualifications - High school diploma or General Education Degree (GED) equivalent. - Minimum of 3 years of dedicated medical provider credentialing experience required. - Demonstrated experience independently managing provider credentialing from application through payer approval and ongoing maintenance. - Hands-on experience with CAQH, NPPES, PECOS, Medicare and Medicaid enrollment, commercial insurance credentialing and contracting, state licensing, and DEA registrations. - Experience managing provider recredentialing, payer revalidations, and credentialing renewals. - Experience communicating directly with commercial insurance companies and payer enrollment representatives. - Behavioral health and/or addiction medicine credentialing experience strongly preferred. - Experience with AthenaOne or other healthcare EMR/practice management systems preferred. - Ability to independently manage multiple providers, payers, applications, deadlines, and credentialing requirements. - Excellent verbal and written communication skills with the ability to work effectively with providers, insurance representatives, credentialing organizations, and internal staff. - Strong organizational skills with exceptional attention to detail. - Self-directed, dependable, and able to work independently while managing multiple priorities and deadlines. - Proficiency in Microsoft Office, including Outlook, Word, and Excel. Originally posted on Himalayas