Credentialing Support Specialist

Job Details:

Job Location:

Practice Support Center 1210 - Dallas, TX 75231, Position Type:
Full Time, Company Conformance Statements

In the performance of their respective tasks and duties all employees are expected to conform to the following:

• Perform quality work within deadlines with or without direct supervision.
• Interact professionally with other employees, customers and suppliers.
• Work effectively as a team contributor on all assignments.
• Work independently while understanding the necessity for communicating and coordinating work efforts with other employees and organizations.

Reporting to the VP of Clinical Integrations & Shared Services, the Credentialing Specialist is responsible for managing all aspects of provider credentialing, recredentialing, payer enrollment, and privileging within an assigned region. This role partners closely with operational leaders to ensure proactive communication regarding credentialing requirements, enrollment time frames, and provider onboarding activities. The Credentialing Specialist helps ensure timely provider activation and uninterrupted participation with contracted health plans.

• Manage all aspects of provider credentialing, recredentialing, payer enrollment, and privileging activities for assigned providers and regions.
• Coordinate enrollment and credentialing processes with contracted commercial, government, and managed care payers.
• Ensure compliance with all payers, regulatory, accreditation, and organizational credentialing requirements.
• Participate in regular meetings with assigned regional leaders to review onboarding status, pending applications, and enrollment needs.
• Compile, maintain, and audit provider credentialing files to ensure all records are complete, accurate, and current.
• Prepare, submit, and monitor credentialing, recredentialing, and payer enrollment applications through completion and approval.
• Maintain current copies of provider licenses, DEA registrations, board certifications, malpractice insurance certificates, and other required credentials.
• Track expiration dates for licenses, certifications, registrations, and other credentials to ensure timely renewals and uninterrupted payer participation.
• Maintain accurate provider information within credentialing software (Modio), CAQH, PECOS, payer portals, and other applicable databases.
• Audit payer directories and provider listings to ensure provider information is accurate and up to date.
• Process provider demographic updates, including practice locations, billing information and other required updates.
• Identify opportunities to improve credentialing workflows and implement standardized best practices.
• Participate in quality improvement initiatives related to credentialing operations, payer enrollment, and data integrity.
• Maintain strict confidentiality of provider, patient, and organizational information.
• Perform additional duties and special projects as assigned.

• High school diploma or equivalent required.
• Associate or bachelor’s degree preferred.

• Minimum of three (3) years of experience in provider credentialing, payer enrollment, medical staff services, or related healthcare administration required.
• Strong knowledge of California Payers.
• Experience supporting multi-site physician practices or healthcare organizations preferred.

• Strong knowledge of provider credentialing, recredentialing, and payer enrollment processes.
• Working knowledge of commercial, Medicare, Medicaid, and managed care payer requirements.
• Experience utilizing CAQH, PECOS, Modio, and payer portals.
• Familiarity with credentialing standards established by NCQA, CMS, and other regulatory agencies.
• Excellen…