Process Associate - US Healthcare Credentialing Specialist

We are seeking an experienced and detail-oriented US Healthcare Credentialing Specialist to join our operational team in Kolkata. In this role, you will lead end-to-end credentialing, re-credentialing, and payer enrollment processes for our US-based psychiatrists, nurse practitioners, and therapists. You will serve as the primary liaison between our medical providers, state licensing boards, and commercial/government insurance payers (such as CAQH, Medicare, Medicaid, Aetna, BCBS, Optum, etc.) to ensure seamless onboarding and zero billing disruptions.

Key Responsibilities:

Provider Credentialing & CAQH Management

• Manage end-to-end credentialing and primary source verification (PSV) for newly hired psychiatrists, nurse practitioners, and licensed mental health clinicians.
• Create, update, and maintain comprehensive provider profiles on CAQH ProView, ensuring 120-day re-attestations are completed promptly.
• Track and maintain expiration dates for state medical licenses, DEA certifications, malpractice insurance (COI), board certifications, and NPI registrations.

Payer Enrollment & Contracting

• Complete and submit payer enrollment applications to commercial insurance carriers, Medicare, and Medicaid.
• Maintain active follow-ups with insurance payer provider relations departments to expedite enrollment and resolve application rejections or delays.
• Maintain a accurate, up-to-date roster of provider panel statuses per health plan.

Compliance & Data Integrity

• Perform Primary Source Verification (PSV) via state boards, NPDB (National Practitioner Data Bank), SAM/OIG sanction lists, and educational bodies.
• Ensure strict adherence to HIPAA guidelines and US healthcare regulatory requirements regarding practitioner documentation and privacy.
• Maintain the internal Credentialing Management System (CMS) and provider directory database with flawless data accuracy.

Collaboration & Communication

• Serve as the main point of contact for providers regarding documentation collection, background verification, and attestation sign-offs.
• Partner closely with the US Billing & Revenue Cycle Management (RCM) team to resolve enrollment-related claims denials and billing hold-ups.

Qualification & Experience Requirements

• Education: Bachelors degree in Healthcare Administration, Commerce, Business, or any related field.
• Experience: 25 years of hands-on experience in US Healthcare Credentialing and Provider Enrollment (Mental Health / Behavioral Health process experience is a strong plus).
• Technical Knowledge:
• Hands-on expertise with CAQH ProView, NPPES (NPI Registry), PECOS (Medicare), and state-specific Medicaid portals.
• Familiarity with credentialing software and Electronic Health Record (EHR) platforms.
• Deep understanding of primary source verification rules and standard US payer enrollment workflows.
• Communication: Exceptional written and spoken English skills to interact clearly with US insurance reps, state boards, and clinical providers.