Credentialing /Enrollment Specialist

Job Summary
We are seeking a detail-oriented and proactive Credentialing Specialist to manage the end-to-end provider credentialing and enrollment processes. This role is critical in ensuring that all providers are properly credentialed with commercial and government payers, maintaining compliance with regulatory standards, and facilitating seamless provider onboarding. The ideal candidate will have strong organizational skills, expertise in credentialing platforms, and the ability to collaborate effectively with internal teams and external partners.

Key Responsibilities
Manage the full lifecycle of provider credentialing and re-credentialing by collecting, verifying, and processing all necessary documentation. You will be responsible for submitting and tracking enrollment applications with various commercial and government payers, ensuring timely and accurate processing. Maintaining and regularly updating provider CAQH profiles is essential to guarantee data consistency across all platforms.

Proactively monitor credential expiration dates and manage re-credentialing timelines to prevent lapses. Handle Electronic Data Interchange (EDI) file submissions related to provider enrollment and updates, ensuring accuracy and compliance. Facilitate Electronic Remittance Advice (ERI) processes to ensure timely receipt and reporting of remittance advices.

Manage Electronic Funds Transfer (EFI) transactions for bulk submissions to CMS and other relevant entities. Collaborate closely with IT teams or clearinghouse partners to troubleshoot and resolve any file transmission errors promptly. Ensure that all credentialing activities comply with payer-specific guidelines as well as federal regulations.

Maintain accurate and comprehensive documentation within credentialing databases, preparing detailed reports on credentialing and enrollment statuses. Follow up with payers as necessary to resolve outstanding issues. Serve as a liaison between internal departments, external payers, and clearinghouses to streamline communication and processes.

Support providers throughout onboarding, credentialing, and any change request processes, providing guidance and education on enrollment procedures and documentation requirements to facilitate smooth transitions.

Required Qualifications
- Proven knowledge and hands-on experience with PECOS, CAQH, Availity, and various payer portals.
- Proficiency in managing EDI and EFI file structures, including understanding transmission protocols and troubleshooting errors.
- Strong organizational skills with the ability to manage multiple credentialing tasks and deadlines effectively.
- Excellent communication skills, both written and verbal, with strong problem-solving capabilities.
- Familiarity with HIPAA regulations and CMS requirements to ensure compliance throughout credentialing and enrollment activities.

Preferred Qualifications and Benefits
While not explicitly stated, candidates with prior experience working directly with CMS bulk submissions and those who have collaborated with IT or clearinghouse partners will find this role well-suited to their skills. The position offers the opportunity to work in a dynamic healthcare environment, contributing to the smooth operation of provider enrollment and credentialing functions.

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This role demands a meticulous professional who can navigate complex regulatory environments while maintaining strong relationships with providers and payers. If you have a passion for healthcare administration and a commitment to accuracy and compliance, we encourage you to apply.