Credentialing Specialist

The Credentialing Specialist is responsible for coordinating all aspects of provider credentialing, recredentialing, and payer enrollment within the physician network. This position ensures that all healthcare providers maintain current credentials and are properly enrolled with contracted payers to support uninterrupted billing and patient care. The role requires meticulous attention to detail, strong organizational skills, and an understanding of regulatory and payer requirements.

Key Responsibilities:

1. Credentialing & Recredentialing

• Collect, verify, and evaluate provider credentials such as medical licenses, board certifications, DEA, education, training, malpractice history, and work experience.
• Perform primary source verification (PSV) in compliance with NCQA, CMS, and payer standards.
• Track and maintain expiration dates for licenses, certifications, and insurance.
• Facilitate timely recredentialing for providers to maintain active participation status.

2. Provider Enrollment & Payer Relations

• Complete and submit provider enrollment and revalidation applications for Medicare, Medicaid, and commercial insurance payers.
• Manage and monitor enrollment progress to ensure providers are activated for billing and network participation.
• Update and maintain CAQH profiles and ensure information accuracy for all providers.
• Communicate with payers to resolve credentialing or enrollment discrepancies.

3. Data & Documentation Management

• Maintain complete and accurate digital provider files in the credentialing database (e.g., Cactus, MD-Staff, or similar systems).
• Generate reports on credentialing and enrollment status for leadership and operational teams.
• Ensure timely updates to internal systems and payer rosters.

4. Compliance & Quality Assurance

• Adhere to all state, federal, and payer credentialing regulations.
• Maintain confidentiality of provider data in accordance with HIPAA.
• Participate in internal audits and quality improvement initiatives.

5. Communication & Team Support

• Serve as a liaison between providers, payers, practice managers, and internal departments.
• Provide clear updates and guidance to providers regarding required documentation and credentialing status.
• Assist with special projects and process improvement efforts as assigned.

Experience:

• Minimum 1–2 years of credentialing or provider enrollment experience in a medical group, IPA, or physician network setting.
• Familiarity with payer enrollment processes, CAQH, NPPES, and PECOS systems.
• Knowledge of NCQA standards and healthcare compliance requirements.

Skills:

• Exceptional attention to detail and organization.
• Strong written and verbal communication skills.
• Proficient in Microsoft Office Suite (Word, Excel, Outlook).
• Ability to manage multiple priorities and meet strict deadlines.
• Experience using credentialing software systems.

Job Type: Full-time

Pay: Rs80,000.00 - Rs120,000.00 per month

Work Location: In person