Credentialing Specialist

We are seeking an experienced Provider Credentialing and Enrollment Specialist to manage the credentialing and enrollment processes for healthcare providers and group practices. This role involves handling initial credentialing, recredentialing, and enrollment with various insurance payers, including Medicare and Medicaid. The ideal candidate will ensure accurate and timely submission of applications, maintain compliance with regulatory requirements, and collaborate closely with revenue cycle management and operations teams to support smooth billing and reimbursement processes. This is an in-person position offering a competitive monthly salary.

Key Responsibilities

Provider Credentialing and Enrollment:
Manage initial credentialing and recredentialing for physicians, DOs, MDs, NPs, PAs, and other eligible healthcare professionals. Complete and maintain applications through CAQH ProView, PECOS, NPPES, and payer-specific portals. Oversee enrollment with commercial insurance payers, Medicare, Medicaid, and other government or regional health plans. Submit provider enrollment applications for new providers and newly established practice locations. Track application progress, effective dates, approval letters, and pending requirements. Follow up with insurance companies to resolve delayed, rejected, or incomplete applications.

Practice and Group Enrollment:
Enroll group practices and healthcare organizations under the appropriate Tax Identification Number (TIN) and organizational NPI. Link individual rendering providers to the correct billing group, practice locations, and payer contracts. Maintain accurate provider demographic, ownership, tax, address, and banking information. Coordinate updates related to new locations, provider departures, practice acquisitions, and changes in ownership or legal structure. Verify payer participation status and effective dates before billing claims.

Documentation and Compliance:
Maintain complete and up-to-date credentialing files for every provider. Verify and track state medical licenses, DEA registrations (when applicable), board certifications, malpractice insurance, and other required documents. Monitor license expirations, recredentialing deadlines, CAQH attestation dates, and payer enrollment renewals. Maintain organized credentialing trackers and supporting documentation. Protect confidential provider information in compliance with HIPAA and company security policies.

Payer Follow-Up and Issue Resolution:
Contact insurance payer enrollment departments to check application status and resolve outstanding requirements. Investigate credentialing-related claim denials, including issues such as provider not enrolled, provider not linked to group, incorrect effective dates, and location enrollment problems. Coordinate with Accounts Receivable, billing, and denial management teams to resolve enrollment-related payment delays. Escalate complex cases to the Billing Manager or Operations Manager as needed. Maintain detailed records of calls, reference numbers, portal updates, and payer correspondence.

Coordination with Revenue Cycle Management and Operations:
Collaborate closely with Billing, Accounts Receivable, Denial Management, and Charge Entry teams. Support new-client onboarding by collecting provider and practice information prior to billing initiation. Confirm payer enrollment readiness for newly onboarded providers and locations. Identify credentialing gaps that could affect clean claim submission and reimbursement. Develop and maintain standard operating procedures (SOPs) and credentialing checklists.

Required Qualifications

- Minimum 3 to 5 years of experience in U.S. medical credentialing and provider enrollment.
- Strong experience with CAQH ProView, PECOS, NPPES, and commercial payer portals.
- Practical knowledge of Medicare, Medicaid, and commercial insurance enrollment processes.
- Experience enrolling individual providers and group practices under the appropriate TIN and NPI.
- Knowledge of provider recredentialing, demographic updates, location additions, and group affiliations.
- Experience coordinating with U.S. insurance payers via phone and online portals.
- Strong written communication, documentation, and follow-up skills.
- Proficiency in Microsoft Excel, Google Sheets, and credentialing trackers.

Compensation and Work Location
The position offers a monthly salary range of Rs100,000 to Rs150,000. This is an in-person role requiring attendance at the designated work location.

If you have a detail-oriented mindset and solid experience in provider credentialing and enrollment, this opportunity offers a dynamic environment to contribute to healthcare operations and revenue cycle success.