Credentialing Specialist

Position Overview

The Credentialing Specialist is responsible for ensuring that providers are properly enrolled, contracted, credentialed, and maintained with all commercial and government payers. This role will work directly with clients, payers, clearinghouses, and internal teams to ensure timely and accurate processing of all credentialing activities.

You will oversee the entire credentialing lifecycle—initial enrollment, re-credentialing, CAQH management, contracting, directory updates, and payer relationships—to ensure our clients remain compliant and able to bill without interruptions.

Key Responsibilities

1. Provider Enrollment & Credentialing

Prepare, submit, and track provider enrollment and credentialing applications with Medicare, Medicaid, and commercial payers.

Complete initial credentialing for new practices and new providers joining existing groups.

Maintain and update CAQH profiles for providers; ensure attestations are up-to-date.

Verify licenses, board certifications, malpractice insurance, NPI, DEA, CDS, and other required documents.

Review and submit facility credentialing documents (if applicable).

2. Contracting & Payer Communication

Establish and maintain provider contracts with payers.

Follow up with payers regularly to ensure timely processing of applications.

Resolve contract discrepancies, panel closures, and credentialing denials.

Notify clients and internal teams about payer participation status and effective dates.

3. Recredentialing & Compliance

Manage recredentialing schedules and ensure no lapses occur.

Monitor expirations for licenses, certificates, malpractice insurance, and compliance documents.

Maintain provider directories and ensure accuracy across payer portals.

4. Client Communication & Documentation

Provide regular updates to clients regarding application status, payer timelines, and next steps.

Maintain detailed records and logs of all submissions, calls, and follow-ups.

Communicate clearly with non-technical staff and physicians to obtain missing documents.

Prepare credentialing reports for internal and client-facing meetings.

5. Cross-Team Collaboration

Work closely with Billing, Insurance Verification, Pre-Authorization, and Client Success teams to prevent delays in claims processing.

Notify RCM teams of effective dates, provider setups, taxonomies, and group affiliations.

Coordinate with IT teams for NPPES/NPI updates as needed.

Ideal Candidate Profile

Required Qualifications

2+ years of direct credentialing and enrollment experience in a healthcare environment

(medical practice, RCM company, hospital, payer enrollment team, etc.)

Strong understanding of Medicare, Medicaid, and commercial payer processes

Experience managing CAQH, PECOS, NPPES, and payer portals

Excellent communication skills—verbal, written, and client-facing

Strong attention to detail and ability to manage multiple providers and deadlines

Proficiency with spreadsheets and credentialing platforms

Preferred Qualifications

Experience with multiple specialties (Primary Care, Internal Medicine, Psychiatry, etc.)

Knowledge of EHR setup and linking providers to groups

Experience with contracting negotiation

Prior work with an RCM or medical billing company

Familiarity with HEDIS/quality programs and directory compliance

Soft Skills

Highly organized with strong follow-up discipline

Professional communication with physicians and administrators

Ability to work independently and with a remote team

Problem-solver who can navigate payer complexities

Friendly, client-first attitude

Key Performance Indicators (KPIs)

Credentialing application accuracy

Timeliness of submissions

Time-to-contract / time-to-approval

Number of follow-ups completed

On-time recredentialing rate

Client satisfaction scores

Minimal delays in billing due to credentialing issues

Industries:Hospital & Health Care

Function: Others