Credentialing & Payer Enrollments Specialist

Overview

Together Women’s Health (TWH) is adding a Credentialing & Payer Enrollments Specialist to be an important member of our accounting team. We are seeking a detail-oriented and experienced Credentialing and Payer Enrollments Specialist to join our healthcare organization. This position is responsible for managing the complete credentialing lifecycle for healthcare providers and ensuring timely enrollment with insurance payers. The ideal candidate will have extensive knowledge of credentialing requirements, payer enrollment processes, and regulatory compliance in the healthcare industry.

The following duties and responsibilities generally reflect the expectations of this job but are not intended to be all inclusive. The essential functions include the most significant tasks and are the essence of why the role exists; removing an essential duty would fundamentally alter the role.

Provider Credentialing

• Initiate and manage the credentialing process for new providers, including physicians, nurse practitioners, physician assistants, and other healthcare professionals
• Collect, verify, and maintain all required credentialing documentation including licenses, certifications, education verification, work history, malpractice insurance, and references
• Ensure compliance with state and federal regulations, accreditation standards, and organizational policies
• Coordinate primary source verification for all credentialing elements
• Maintain detailed tracking systems and databases for all credentialing activities
• Prepare and submit credentialing applications to hospitals, health systems, and other healthcare facilities

Payer Enrollment Management

• Complete enrollment applications for providers with commercial insurance plans, Medicare, Medicaid, and other third-party payers
• Monitor enrollment status and follow up on pending applications
• Maintain current knowledge of payer-specific enrollment requirements and deadlines
• Coordinate with providers to obtain necessary documentation and signatures
• Ensure accurate provider demographic and practice information across all payer systems
• Manage provider directory updates and changes

Maintenance and Re-credentialing

• Monitor expiration dates for licenses, certifications, malpractice insurance, and other time-sensitive documents
• Initiate re-credentialing processes in advance of expiration dates
• Update provider information with payers as needed for address changes, specialty additions, or other modifications
• Maintain organized filing systems for all credentialing and enrollment documentation

Compliance and Quality Assurance

• Ensure all credentialing activities comply with NCQA, URAC, Joint Commission, and other relevant standards
• Conduct regular audits of credentialing files to ensure completeness and accuracy
• Stay current with changing regulations and industry best practices
• Participate in accreditation surveys and provide necessary documentation

Communication and Coordination

• Serve as primary liaison between providers, payers, and internal stakeholders
• Provide regular status updates to leadership and providers regarding credentialing progress
• Resolve credentialing issues and barriers in a timely manner
• Collaborate with Revenue Cycle Management team to ensure billing capability following enrollment completion

REQUIRED EDUCATION, EXPERIENCE, KNOWLEDGE, SKILLS, AND ABILITIES:

• Minimum 3 years of experience in healthcare credentialing and payer enrollment
• 2-year college degree with additional training, experience and related certifications is required
• Proficiency in credentialing software platforms (CAQH Pro View, PECOS, state Medicaid portals)
• Strong computer skills including Microsoft Office Suite, database management, and electronic filing systems
• Experience with primary source verification processes and requirements
• Familiarity with NPDB, OIG exclusion lists, and other verification databases
• Previous experience with credentialing software systems and databases
• Knowledge of medical terminology and healthcare organizational structures
• Experience with Athena Healthcare EMR or Modio Health software is a plus
• Exceptional attention to detail and accuracy
• Strong organizational and time…