Credentialing & Enrollment Specialist II

This is a fully remote position, open to applicants in United States.

📋 Description

• Carry out tasks for provider onboarding readiness and verify completeness of intake packets.

• Prepare and submit applications for initial credentialing and re-credentialing.

• Submit and oversee primary source verifications through the Credentialing Verification Organization (CVO).

• Conduct Primary Source Verification (PSV) in accordance with departmental policies and NCQA standards when not done by CVO.

• Review files processed by CVO for accuracy and completeness.

• Handle changes in provider status, including terminations and reactivations.

• Gather and follow up on any missing documentation from providers.

• Monitor and manage provider expirables and renewal timelines.

• Complete and submit enrollment applications for groups and individuals to both commercial and government payers.

• Follow up on submitted enrollment applications until they are finalized.

• Execute roster additions, updates, and terminations as instructed by the Senior IC.

• Correct any discrepancies in rosters.

• Maintain contact lists for payers and manage portal access.

• Track enrollment statuses and update Salesforce as required.

• Oversee maintenance of CAQH and PECOS profiles.

• Follow up on payer issue tickets and cases.

• Manage communications regarding onboarding, status updates, and documentation guidance for providers.

• Handle the intake and routing of provider issues.

• Follow up with providers regarding any missing items.

• Assist with triage of claim denials related to enrollment.

• Support coordination of provider billing activation.

• Help resolve billing issues related to rosters.

• Collect audit evidence as directed by the Senior IC.

• Prepare files for delegated credentialing.

• Conduct quality assurance on credentialing files.

• Collect and verify provider malpractice policies and insurance documentation.

• Monitor insurance expiration dates and follow up on renewals.

• Ensure provider demographic data is accurate across credentialing systems, CAQH, and payer records.

• Maintain records on the credentialing platform and internal tracking systems.

• Manage accounts on payer portals.

• Act as a resource for members of the Credentialing Specialist I team.

• Support team operations through limited subject matter expert responsibilities.

• Report directly to the Manager of Credentialing and Enrollment.

⛳️ Requirements

• A minimum of 3 years of experience in credentialing and/or enrollment operations.

• Solid understanding of NCQA standards, CAQH, and payer enrollment processes.

• Experience with enrollment for both commercial and government payers is preferred.

• Proficient with payer portals (CAQH, PECOS, Availity, and payer-specific portals).

• Exceptional attention to detail and strong documentation skills.

• Ability to manage multiple priorities and consistently meet deadlines.

🏝️ Benefits

• A competitive salary.

• Comprehensive health care coverage (medical, dental, vision) fully paid.

• Pet Insurance.

• Life Insurance & Short / Long Term Disability.

• 401k Plan.

• Unlimited PTO and sick leave.

• Parental Leave.

• Flexibility to work remotely and choose a schedule that suits you best.

• Additional memberships and perks.

• Opportunities for continuous learning.

• A flexible work environment.

• Opportunities for cross-functional collaboration.

• Equal employment opportunities based on merit, competence, and performance.