Payor Credentialing Specialist; remote

Payor Credentialing Specialist (remote)

Behavioral Health Group – BHG

Remote Position – Requires Payor Credentialing and Payor Enrollment experience.

• Lead, coordinate, monitor, and maintain the payor and provider credentialing and re‑credentialing processes.
• Facilitate all aspects of BHG’s payor credentialing including payor enrollments, revalidations, maintenance, license updates, and follow‑up on payor‑credentialing related A/R issues.
• Interpret and ensure compliance with accrediting and regulatory agencies, and maintain knowledge of statutes and laws related to payor credentialing and enrollment.
• Ensure the accuracy and integrity of the credentialing database system and related applications.
• Complete the enrollment and credentialing process for facilities and providers with insurances, ensuring all payor criteria are met.
• Lead, coordinate, and monitor the collection, review, and analysis of payor enrollment applications.
• Ensure accuracy and completeness of payor enrollment submissions, including supporting documentation.
• Follow up with providers and insurances for timely credentialing and enrollment processes.
• Monitor application progress and follow up with payors as needed until confirmation of credentialing and network load is complete.
• Identify issues requiring additional investigation, validate discrepancies, and ensure appropriate follow‑up.
• Review and update (if necessary) health plan directories, agencies, and other entities for current and accurate provider information.
• Respond to inquiries from other healthcare organizations and interface with internal and external customers on day‑to‑day credentialing and enrollment issues as they arise.
• Utilize the credentialing database to optimize efficiency, and perform query, report, and document generation.
• Enter and maintain accurate data input into Credential Stream, PECOS, NPPES, CAQH, Optum, Availity, and other payor portals.
• Verify provider accuracy in payor directories.
• Provide support with managed care delegated credentialing audits and conduct internal file audits.

• Ensure compliance with regulatory bodies (Joint Commission, NCQA, URAC, CMS, federal and state laws) and policies and procedures in all aspects of the payor credentialing process.

• Attend and complete all required trainings as assigned by the Director.
• Demonstrate professionalism, respect, and caring in all interactions with patients and team members.
• Maintain a calm demeanor and make good judgments with confidential and sensitive issues.

• 3 to 5 years of payor credentialing/enrollment experience.

• Bachelor’s degree preferred or comparable work experience.
• Current CPCS or CPMSM certification or working towards certifications.
• Experience or working knowledge of full credentialing cycles; initial payor credentialing/enrollment, maintenance and revalidation.
• Experience or working knowledge of Credential Stream credentialing platform or other credentialing database software.
• Excellent attention to detail, problem‑solving, critical thinking, and analytical skills.
• Strong working knowledge of word processing, spreadsheets, data entry, database experience and other computer related skills.
• Proficiency in Adobe, Excel, PowerPoint, Word, Outlook, and other Microsoft Office applications.
• Well organized, capable of juggling multiple projects and accustomed to tight deadlines.
• Ability to work effectively and independently with both clinical and non‑clinical colleagues.
• Ability to perform research independently.

• Speaking and hearing ability sufficient to communicate effectively by phone or in person at normal volumes.
• Vision adequate to read correspondence, computer screen, forms, etc.
• Sit for long periods of time, with some bending, stooping and stretching.
• Variable workload, periodic high activity level.
• Keyboarding for long periods of time.

Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this job to the extent such accommodation does not create an undue hardship on the business.

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