Credentialing and Enrollment Specialist

The Credentialing and Enrollment Specialist is responsible for performing the credentialing and enrollment process for healthcare providers. This role ensures that all providers meet the necessary qualifications and comply with regulatory requirements to deliver patient care. The Specialist will work closely with healthcare providers, insurance companies, and government agencies to facilitate and maintain provider networks. You will report directly to the Director of Payer Credentialing.  

What you’ll do: 

• Document and verify the credentials of healthcare providers, including licenses, certifications, education, and work history.
• Submit hospital affiliation applications and collaborate with onboarding providers and practitioners.
• Coordinate credentialing files with leadership and credentials committees. 
• Assure compliance with credentialing, privileging, facility, accreditation, and health plan regulatory requirements.
• Work expirables and maintain accurate databases, online systems, and documentation related to provider credentialing and enrollment.
• Facilitate the enrollment process for providers with insurance companies, health plans, and government programs.
• Prepare and submit enrollment applications and documents to insurance companies, health plans, and regulatory bodies.
• Track and manage the status of applications and resolve issues or discrepancies.
• Ensure timely re-credentialing and re-enrollment.
• Prepare and submit weekly and monthly reports on set cadence.
• Manage communications with insurance companies and other stakeholders. Address and resolve any payer issues or concerns.
• Perform payer contract verification, request payer contract agreements, and ensure providers are enrolled with health plans within designated timeframes.
• Research and document clinical guidelines, fee schedules, and payer contract changes.
• Ensure compliance with national, state, and local regulatory requirements.
• Attend meetings, trainings, and reviews as necessary.
• Additional duties as assigned. 

What you’ll need: 

• Associate’s degree in healthcare administration, business, or a related field.
• Minimum of 2 years of experience in provider credentialing and payer enrollment.
• Familiarity with healthcare regulations, credentialing standards, and insurance processes.  
• Cardiology practice experience preferred. 

Interpersonal Skills 

• Ability to communicate appropriately and professionally with practitioners, stakeholders, and health plans, including sensitive and confidential information.
• Strong organizational and time management skills.
• Excellent attention to detail and accuracy.
• Ability to work independently, meet deadlines, and prioritize effectively. 

Software Skills 

• Proficiency in Microsoft Office Suite (Word, Excel, Outlook).
• Experience with credentialing software and online systems, including Availity, PECOS, state Medicaid websites, and payer portals. AthenaHealth and Verity CredentialStream experience preferred. 

Additional Information 

Full-time base salary range of $47,000 to $60,000 per year dependent on years of experience and includes medical, dental, vision, and a 401K match. This role will have minimal travel.