Job Title: Provider Enrollment and Credentialing Specialist

Reports to: Provider Enrollment and Credentialing Supervisor

Employment Status: Full-Time

FLSA Status: Non-Exempt

Job Summary:

We are seeking an experienced and detail-oriented Provider Enrollment and Credentialing Specialist to join our team. In this role, you will be responsible for managing the process of provider enrollment and credentialing for our organization, ensuring that our healthcare providers are properly qualified and enrolled with insurance networks.

Duties/Responsibilities:

• Manage all aspects of the provider enrollment and credentialing process, including initial applications, re-credentialing, and maintaining provider information in all necessary systems.

• Performs primary source verification of provider credentials, including education, training, licensure, and certifications.

• Coordinates with insurance payers to complete provider enrollment applications.

• Manages delegated credentialing agreements, ensuring that our internal processes meet insurance company standards.

• Works with healthcare providers to complete necessary paperwork and answer questions about the enrollment and credentialing process.

• Stays up to date with changes in regulations and standards from organizations such as the National Committee for Quality Assurance (NCQA), The Joint Commission (TJC), and the Centers for Medicare and Medicaid Services (CMS).

• Maintains accurate records and ensures that all credentialing documents are current and comply with industry standards.

• Handles provider privilege process, collaborating with the medical staff office when needed.

• Works collaboratively with other departments to resolve credentialing and enrollment issues.

• All other duties as assigned.

Required Skills/Abilities:

• Proficiency in Microsoft Office Suite, specifically Excel and Word.

• Excellent attention to detail and organizational skills.

• Strong written and verbal communication skills.

• Ability to handle sensitive information confidentially.

• Experience in a managed care setting is preferred.

Education and Experience:

• A minimum of 2 years of experience in provider enrollment and credentialing.

• In-depth understanding of healthcare regulations, accreditation standards, and credentialing requirements.