Job Title

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 ProView 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, UnitedHealthcare, 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 ID). - 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 ProView: 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, UnitedHealthcare) for status tracking and electronic application submission. - Credentialing Software: Proficiency in enterprise platforms like Modio, Echo, or VerityStream 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.