Credentialing Specialist with 25% Night Differential | Work From Home Setup
4 weeks ago
Overview
The Credentialing Specialist is responsible for the timely and accurate enrollment and re-enrollment of healthcare clinicians with government and commercial insurance payors. The role ensures that all required documentation is submitted to payors to establish and maintain participation status and billing privileges, thereby supporting timely reimbursement and compliance with regulatory and payor-specific requirements.
Responsibilities- Prepare and submit provider enrollment and re-enrollment applications to Medicare, Medicaid, and commercial insurance payors — including Blue Cross Blue Shield and regional subsidiaries.
- Maintain current knowledge of payor requirements, policies, and processes.
- Monitor application status and follow up with payors to ensure timely processing.
- Track and manage enrollment deadlines, effective dates, CAQH updates, and recredentialing requirements.
- Ensure accuracy and completeness of provider data in internal systems (e.g., NPI, licensure, DEA, malpractice, CV).
- Communicate enrollment progress to internal stakeholders and escalate delays or issues as needed.
- Maintain and audit files to ensure documentation is current and compliant with regulatory standards.
- Assist with roster submissions, EFT forms, W-9s, and group affiliations as required.
- Resolve enrollment issues that impact claims payment, including mismatch errors, taxonomy/NPI conflicts, and provider location linking.
- Collaborate with credentialing teams, billing staff, and operations to support seamless onboarding of new providers.
- Communicate effectively with clinicians, payors, and internal departments to resolve issues and clarify requirements.
- Experience with any related medical billing or credentialing software.
- Skilled in Microsoft Office (Excel, Outlook, Word) and database systems.
- Familiarity with NPPES, PECOS, CAQH, Availity, and provider portals.
- Knowledge of Medicare, Medicaid, and commercial payor enrollment processes.
- Knowledge of state-specific Medicaid programs and enrollment nuances.
- Demonstrated organizational skills; manages multiple priorities in a fast-paced environment.
- Adapts quickly to shifting priorities while meeting strict deadlines.
- Attention to detail and accuracy in handling data and documentation.
- Self-motivated and resourceful in resolving issues and driving improvements.
- Clear and coherent both written and verbal communication skills in English to effectively diverse with the team members.
- High school diploma or equivalent required.
- Minimum of two (2) years of experience in healthcare provider enrollment, credentialing, or revenue cycle.
- Must have stable employment history.
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