Credentialing Specialist

Company: Credifide

Location: Mohali

Shift: US Timings

Working Days: Monday to Friday (On-site)

Job Type: Full-time

Role Summary

The Credentialing Specialist is responsible for managing the end-to-end provider enrollment and primary source verification process for an assigned caseload of providers. This role ensures insurance panel applications, re-credentialing, and hospital privileging are completed accurately and on schedule, working closely with the Credentialing Team Lead on complex or escalated files.

Key Responsibilities

• Application Management: Prepare, submit, and follow up on initial credentialing and re-credentialing applications for various specialties (Medicare, Medicaid, and Commercial payers).
• Primary Source Verification: Conduct primary source verification of provider education, licensure, certifications, and work history in line with NCQA and payer standards.
• Data Management: Maintain accurate, up-to-date provider profiles in CAQH, NPPES, and PECOS.
• Quality Control: Review own applications for accuracy and completeness before submission to minimize delays or denials.
• Payer Follow-up: Track submitted applications and follow up with payers to resolve pended applications, enrollment discrepancies, or missing information.
• Compliance Monitoring: Monitor expiration dates for provider licenses, DEAs, and board certifications, and initiate timely renewals.
• Reporting: Keep the centralized tracking database/spreadsheet updated with the current status of assigned provider files.
• Collaboration: Escalate complex credentialing roadblocks or multi-state enrollment issues to the Team Lead/Manager as needed.

Required Skills & Experience

• Experience: 3-4 years of experience in medical credentialing and provider enrollment.
• Knowledge: Working knowledge of NCQA standards, CMS guidelines, and state-specific payer requirements.
• Technical Proficiency: Hands-on experience with CAQH ProView, PECOS, and NPPES (NPI) portals. Proficient in Excel for data tracking.
• Communication: Clear, professional communication skills for interacting with providers, office managers, and insurance representatives.
• Detail-Oriented: Strong attention to detail to catch errors in provider documentation that could lead to claim denials.