Managed Care Credentialing Coordinator

SUMMARY:  

Coordinates physician and allied health professional credentialing and enrollment activities with hospitals, health plans, and regulatory organizations. This role prepares and submits credentialing applications, maintains credentialing records, and supports physician participation in managed care networks, Medicare, and commercial insurance programs. The Managed Care Credentialing Coordinator communicates with internal departments, insurance carriers, and regulatory entities to ensure timely credentialing, accurate provider records, and compliance with applicable policies and procedures.

Primary Responsibilities

1. Prepares and submits credentialing and enrollment applications for physicians and allied health professionals with hospitals, health plans, Medicare, and commercial insurance carriers.
2. Coordinates initial credentialing and re-credentialing activities for providers participating in managed care networks.
3. Prepares and submits applications for physician reappointments to hospitals and other affiliated healthcare organizations.
4. Submits new provider information and updates to the National Provider Identifier (NPI) registry and Council for Affordable Quality Healthcare (CAQH).
5. Maintains credentialing files for physicians and allied health professionals including licenses, certifications, and regulatory documentation.
6. Monitors expiration dates for provider licenses, Drug Enforcement Administration (DEA) registrations, professional liability insurance, and specialty board certifications.
7. Prepares and submits renewal applications and documentation prior to expiration deadlines.
8. Assists physicians and staff with managed care contracting and credentialing questions.
9. Coordinates communication between the Clinic, physicians, insurance companies, and credentialing organizations regarding credentialing status and requirements.
10. Updates provider fee schedules and managed care contract information as required.
11. Serves as liaison between Clinic management and managed care representatives at insurance companies.
12. Maintains documentation of managed care network participation and provider enrollment records.
13. Ensures credentialing records are accurate and maintained in accordance with regulatory and organizational requirements.
14. Participates in departmental projects and process improvement initiatives as directed.
15. Maintains confidentiality of provider and organizational information.
16. Perform all other duties as assigned.

Education and Experience

• High school diploma or equivalent required.
• Experience with physician credentialing, managed care enrollment, and healthcare administration required.
• Certified Medical Staff Coordinator (CMSC) or Certified Provider Credentialing Specialist (CPCS) preferred but not required.
• Experience with credentialing software and platforms required.

Required Skills and Abilities

• Strong organizational and time management skills.
• Strong attention to detail when managing credentialing documentation and regulatory requirements.
• Effective written and verbal communication skills.
• Knowledge of physician credentialing processes and healthcare payer requirements.
• Ability to maintain confidential and sensitive information.
• Ability to coordinate multiple credentialing activities and deadlines simultaneously.
• Strong customer service skills when interacting with providers, staff, and insurance representatives.
• Professional interpersonal skills with the ability to interact effectively with leadership, physicians, and peers.
• Proficiency in Microsoft Office (Word, Excel, Outlook, and PowerPoint).
• Proficiency in electronic medical record platforms (Epic).

Physical Requirements

• Ability to sit for extended periods while working at a computer workstation.
• Frequent use of hands and fingers for typing, data entry, and phone use.
• Ability to speak clearly and hear well enough to communicate by phone and in person.
• Occasional standing, walking, bending, and reaching.
• Ability to lift and carry up to 25 pounds (files, office supplies)
• Visual acuity to read computer screens.
• Ability to focus for long periods and manage high-volume, detail-oriented tasks.