Credentialing Specialist

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

📋 Description

• Oversee the initial credentialing and recredentialing processes for providers with commercial insurance companies, Medicare, Medicaid, and other contracted payers.

• Complete and monitor payer enrollment applications from submission to approval.

• Add and modify provider details, supervising physicians, practice locations, and services within payer contracts.

• Maintain credentialing records in CAQH, NPPES, PECOS, state licensing boards, DEA registrations, malpractice coverage, AthenaOne, and other relevant systems.

• Track expiration dates and execute renewals, revalidations, and credentialing maintenance to avoid participation gaps.

• Coordinate credentialing and payer enrollment for newly onboarded providers.

• Follow up with insurance companies and credentialing entities regarding application progress, documentation, and enrollment challenges.

• Investigate payer-specific requirements and relay updates to leadership.

• Ensure accurate maintenance of credentialing files, documentation, and tracking systems.

• Support credentialing audits and respond to payer requests for additional documentation.

• Identify and communicate potential issues that may impact provider participation.

• Review and manage payer contracts and provider participation details.

• Act as the primary liaison for credentialing-related communications with payers and enrollment representatives.

• Foster professional relationships with payers and follow up on unresolved issues.

• Collaborate with providers and leadership to gather necessary documentation.

• Assist leadership in researching new insurance networks and opportunities for payer participation.

• Ensure that providers are enrolled with relevant payers prior to delivering services that require insurance participation.

• Uphold confidentiality and adhere to HIPAA, Federal, State, and payer regulations.

• Acknowledge and advocate for patients' rights and responsibilities while maintaining privacy and confidentiality.

• Take on additional credentialing, payer relations, and administrative tasks as assigned.

⛳️ Requirements

• High school diploma or equivalent General Education Degree (GED) required.

• At least 3 years of focused experience in medical provider credentialing is necessary.

• Proven experience in independently managing provider credentialing from application to payer approval and ongoing maintenance.

• Practical experience with CAQH, NPPES, PECOS, Medicare and Medicaid enrollment, commercial insurance credentialing and contracting, state licensing, and DEA registrations.

• Experience in managing provider recredentialing, payer revalidations, and renewal processes.

• Direct communication experience with commercial insurance companies and payer enrollment representatives is essential.

• Credentialing experience in behavioral health and/or addiction medicine is highly preferred.

• Familiarity with AthenaOne or other healthcare EMR/practice management systems is preferred.

• Ability to independently handle multiple providers, payers, applications, deadlines, and credentialing needs.

• Excellent verbal and written communication skills, capable of engaging effectively with providers, insurance representatives, credentialing organizations, and internal staff.

• Strong organizational capabilities with exceptional attention to detail.

• Self-motivated, reliable, and able to work independently while juggling multiple priorities and deadlines.

• Proficient in Microsoft Office applications, including Outlook, Word, and Excel.

🏝️ Benefits

• Work from Home.

• Monday to Friday schedule.

• Flexible schedule to a certain extent.

• Observance of U.S. holidays.