Credentialing Specialist

Job Summary

The Credentialing Specialist is responsible for managing the end-to-end provider

credentialing and enrollment process with insurance payers. The role ensures that

healthcare providers are properly credentialed, enrolled, and re-credentialed to maintain

uninterrupted revenue flow and compliance with payer and regulatory requirements.

Key Responsibilities

1. Provider Enrollment & Credentialing

• Handle end-to-end credentialing process for physicians and healthcare providers.
• Prepare and submit provider enrollment applications to insurance payers.
• Complete CAQH registration, updates, and attestations.
• Ensure timely submission of new enrollments, re-credentialing, and updates.

2. Follow-ups & Payer Communication

• Communicate with insurance companies to track application status.
• Follow up on pending, rejected, or incomplete applications.
• Resolve enrollment-related issues with payers.

3. Documentation & Compliance

• Collect and verify provider documents (licenses, DEA, board certification,

malpractice insurance, NPI, etc.).

• Maintain accurate and updated provider records.
• Ensure compliance with payer and regulatory guidelines.

4. Re-Credentialing & Maintenance

• Track re-credentialing timelines and renewal dates.
• Maintain a credentialing database and monitoring system.
• Ensure no lapse in provider participation with payers.

5. Reporting & Coordination

• Maintain credentialing trackers and MIS reports.
• Coordinate with billing, AR, and operations teams for smooth provider activation.
• Support audits related to credentialing documentation.

Required Qualifications

• 1-3+ years of experience in provider credentialing (US Healthcare preferred).
• Strong knowledge of CAQH, NPI, PECOS, and insurance payer portals.
• Familiarity with Medicare, Medicaid, and commercial payer enrollment.
• Good communication and follow-up skills.
• Attention to detail and ability to meet deadlines.

Preferred Skills

• Experience in RCM / Medical Billing company.
• Knowledge of HIPAA compliance.
• Ability to manage multiple providers simultaneously.
• Strong organizational and documentation skills.