Credentialing Specialist

Location: Mohali

Company:
Credifide

Location:

Mohali

Shift: US Timings
Working Days:
Monday to Friday (On-site)
Job Type: Full-time

Role Summary
The Credentialing Specialist is responsible for managing the end-to-end provider enrollment and primary source verification process for an assigned caseload of providers. This role ensures insurance panel applications, re-credentialing, and hospital privileging are completed accurately and on schedule, working closely with the Credentialing Team Lead on complex or escalated files.

Key Responsibilities
Application Management:  Prepare, submit, and follow up on initial credentialing and re-credentialing applications for various specialties (Medicare, Medicaid, and Commercial payers).
Primary Source Verification:  Conduct primary source verification of provider education, licensure, certifications, and work history in line with NCQA and payer standards.
Data Management:  Maintain accurate, up-to-date provider profiles in CAQH, NPPES, and PECOS.
Quality Control:
Review own applications for accuracy and completeness before submission to minimize delays or denials.
Payer Follow-up:  Track submitted applications and follow up with payers to resolve pended applications, enrollment discrepancies, or missing information.
Compliance Monitoring:  Monitor expiration dates for provider licenses, DEAs, and board certifications, and initiate timely renewals.
Reporting:  Keep the centralized tracking database/spreadsheet updated with the current status of assigned provider files.

Collaboration:

Escalate complex credentialing roadblocks or multi-state enrollment issues to the Team Lead/Manager as needed.

Required Skills & Experience

Experience:

3-4 years of experience in medical credentialing and provider enrollment.
Knowledge:  Working knowledge of NCQA standards, CMS guidelines, and state-specific payer requirements.
Technical Proficiency:  Hands-on experience with CAQH Pro View, PECOS, and NPPES (NPI) portals. Proficient in Excel for data tracking.
Communication:  Clear, professional communication skills for interacting with providers, office managers, and insurance representatives.
Detail-Oriented:  Strong attention to detail to catch errors in provider documentation that could lead to claim denials.