Credentialing Specialist; Sr. Provider Payer Enrollment

Position: Credentialing Specialist (Sr. Provider Payer Enrollment)
About the Role:

We are seeking a highly skilled and autonomous Credentialing Specialist to manage the end-to-end provider payer enrollment process. Unlike roles that focus on data entry and "handoffs," this position requires a subject matter expert who can independently navigate federal and state systems (PECOS, NPPES, Medicaid portals) and commercial payer applications from initial submission to final approval.

Key Responsibilities:

End-to-End Execution:

1. Federal & State Enrollment (Medicare/Medicaid)

- Independently manage the complete Medicare enrollment process via PECOS, including the preparation and submission of CMS-855I, 855B, 855R, and DME applications.
- Manage the full NPI (Type 1 and Type
2) lifecycle through NPPES, including new registrations and updates.
- Directly submit and track state-specific Medicaid enrollment applications through state portals without departmental handoffs.
- Maintain and navigate the Identity & Access (I&A) Management System to manage authorized official roles.

2. CAQH & Commercial Payer Management

- Take 100% ownership of CAQH Pro View profiles: initial setup, quarterly re-attestations, and ensuring all documentation (COI, licenses, board certs) is current.
- Execute full-cycle commercial credentialing through Availity and individual payer portals (Anthem, BCBS, Aetna, Cigna, United Healthcare, etc.).
- Manage enrollment for specialized payers including Tricare, VA, and Managed Care Organizations (MCOs).

3. Data Systems & Compliance

- Utilize credentialing software (e.g., Modio, Echo) to track application status, expiration dates, and provider rosters.
- Perform primary source verification (PSV) to ensure all provider data is accurate before submission.
- Proactively manage the re-credentialing cycle to prevent lapses in provider participation or billing "hold" periods.

4. Communication & Relationship Management

- Serve as the primary point of contact for providers, medical directors, and insurance network trackers.
- Resolve "pended" applications by communicating directly with payer representatives to troubleshoot and provide missing information.

Professional

Experience:

- Minimum 3–5 years of direct experience in healthcare provider enrollment and payer credentialing.
- Full-Cycle Proficiency:
Proven track record of managing the entire enrollment lifecycle—from initial data collection and NPI creation to CAQH setup, application submission, and final approval (receiving the Provider ).
- Governmental Payer Mastery:
Deep, hands-on experience with federal and state enrollment, specifically:
- Medicare:
Navigating PECOS to submit CMS-855I, 855B, and 855R forms.
- Medicaid:
Directly submitting applications through state-specific portals (e.g., Nevada Medicaid, Medi-Cal, etc.).
- NPI Management:
Demonstrated ability to register and maintain NPI Type 1 (Individual) and Type 2 (Group/Organization) via NPPES.
- Direct Communication:
Comfortable acting as the liaison between the provider, the practice manager, and the insurance network representatives.

Technical Skills & Systems

- CAQH Pro View:
Expert-level knowledge of profile creation, document uploading, and quarterly re-attestations.
- Payer Portals:
Mastery of Availity and individual commercial payer portals (Aetna, Cigna, Anthem, United Healthcare) for status tracking and electronic application submission.
- Credentialing Software:
Proficiency in enterprise platforms like Modio, Echo, or Verity Stream for database management and expiration tracking.
- Regulatory Knowledge:
Familiarity with NCQA (National Committee for Quality Assurance) and URAC standards to ensure all applications meet compliance benchmarks.