Provider Enrollment & Credentialing Coordinator

The Provider Enrollment Coordinator performs provider enrollment functions for delegated, non-delegated, government, and third-party payers/vendors. This role supports enrollment, reenrollment, profile maintenance, updates, disenrollments, and resolution of payer-related issues. The coordinator ensures that provider records are accurate, compliant, and maintained in accordance with enrollment timelines, payer requirements, and internal standards. While the core focus is enrollment, the role may support credentialing activities as needed to maintain workflow continuity and compliance.

• Coordinate enrollment and credentialing tasks for delegated, non-delegated, government, and third-party payers/vendors.
• Assist in preparing, submitting, and tracking individual and group provider enrollment submissions, including applications, rosters, revalidations, group linkages, demographic updates, and terminations.
• Support a variety of enrollment scenarios by preparing documentation, completing standard applications, performing data validation, and tracking enrollment progress. Support escalations or complex cases by gathering requirements, identifying issues, and assisting with resolution follow-up.
• Support quality assurance (QA) efforts by reviewing application components for completeness and flagging potential compliance issues based on payer-specific guidelines. Ensure documentation integrity.
• Maintain accurate and organized provider files in accordance with internal record-keeping standards.
• Utilize up-to-date payer forms and enrollment documentation in alignment with established departmental SOPs and workflow guides.
• Maintain and update payer portals (e.g., PECOS, Availity, eMedNY) to support accurate provider profiles and track enrollment status; assist with identifying the appropriate application type (e.g., full application, group link, revalidation); and support submission of follow-up applications when needed to complete or correct enrollment records.
• Track and document enrollment status from submission through confirmation using internal tools, ensuring timely processing and accurate system updates. Conduct systematic follow-up via email, phone, and payer systems to confirm application receipt and approval. Provide regular updates on outstanding requests, aging items, and any delays impacting submission timelines. Escalate incomplete submissions, delays, or errors in accordance with established escalation protocols.
• Support profile maintenance for providers by processing updates to licenses, DEA registrations, specialties, TINs, service addresses, hospital affiliations, board certifications, and more to ensure enrollment records remain current and compliant.
• Follow up with departments to obtain missing documentation or signatures to support timely application submission.
• Log, troubleshoot, and track enrollment-related issues such as denials/underpayments, authorization issues, or other participation errors. Collaborate with internal departments and payer contacts to complete a comprehensive root-cause analysis, following through to resolution to minimize adverse impact to revenue and patient/provider abrasion. Escalate issues appropriately for review and resolution.
• Perform routine roster audits for lower-volume payers to identify and resolve discrepancies. (EX: PAR/NONPAR Status:
  Identify and coordinate resolution of participation discrepancies. Demographics:
  Verify NPI, TIN, and address accuracy across internal records and payer rosters. Credentialing:
  Reconcile licenses, board certifications, and specialties with payer records. Other: Support audit efforts related to recredentialing timelines and Medicaid enrollment status.)
• Work collaboratively with fellow team members to regularly evaluate the effectiveness of department Standard Operating Procedures and workflows and identify gaps. Provides feedback and recommendations to the supervisor for improvements. Implements approved changes.
• Support special projects such as open enrollment, payer file transitions, and bulk data entry initiatives under the guidance of senior team members.
• Maintain workflow tools, trackers, and templates to improve efficiency and accuracy.
• Monitor and report recurring issues in enrollment processes or payer responses to help inform workflow improvements.

• Performs compliance checks and quality assurance activities to maintain the integrity of data and ensure adherence to standard operating procedures.
• Stay informed and comply with current HIPAA, NCQA, payer requirements, and regulatory guidelines relevant to enrollment activities.
• Support process improvement efforts by identifying workflow inefficiencies and submitting recommendations for system or procedural enhancements.
• Participate in payer meetings to share audit findings, enrollment updates, and outstanding issues for resolution.
• Participate and represent PEG in internal meetings, cross‑functional work groups, audit preparation, and department…