Experienced Credentialing Specialist in medical billing

Here's Credentialing

Job Title

Credentialing Specialist — Medical Billing / Provider Enrollment

Position Summary

The Credentialing Specialist is responsible for managing the full lifecycle of provider credentialing and enrollment with payers (commercial, Medicare, Medicaid, third‑party networks) to ensure that providers are properly authorized to bill and receive reimbursement. This role liaises between providers, payers, billing teams, and internal departments to maintain compliance, minimize credentialing delays, and support revenue integrity.

Key Responsibilities / Duties

• Provider Credentialing & Enrollment
• Prepare, compile, and submit initial credentialing applications to payers, Medicare/Medicaid, IPAs, health networks.
• Manage re‑credentialing and renewals of existing provider credentials.
• Maintain and update provider profiles (e.g. CAQH, NPPES, PECOS, payer portals).
• Obtain and track provider identifiers (Provider IDs, NPI, Tax IDs, etc.).
• Coordinate with providers (physicians, DME, therapists, clinics) to gather required documentation (licenses, board certifications, CVs, malpractice insurance, etc.).
• Follow up on application status, resolve discrepancies, and expedite submissions.
• Verification & Compliance
• Perform primary source verification (PSV) of credentials (licensure boards, education, certifications).
• Audit credentialing files to ensure completeness, accuracy, and consistency.
• Monitor credential expiration dates (licenses, DEA, certifications) and trigger renewals proactively.
• Ensure compliance with payer, state, and regulatory credentialing requirements, including policy changes and updates.
• Data & Documentation Management
• Maintain credentialing databases, logs, tracking systems, and reports on status metrics (turnaround time, backlog, approval rates).
• Document interactions with payers and providers, maintain records of submissions, denials, and appeals.
• Generate periodic credentialing status reports for management and internal stakeholders.
• Stakeholder Communication & Issue Resolution
• Communicate with payers and insurance networks to resolve credentialing issues, contract queries, missing documentation, and provider disputes.
• Liaise with billing, contracting, HR, compliance, legal, and provider offices for credentialing‑related matters.
• Support billing teams in credential‑related denials or rejections (for example, provider not enrolled).
• Process Improvement & Quality Assurance
• Identify credentialing process bottlenecks and suggest workflow improvements.
• Participate in audits, quality checks, and compliance reviews.
• Stay current on industry trends, payer credentialing rules, regulatory changes, and best practices in provider enrollment.

Qualifications & Requirements

• Education: Bachelor's degree preferred (Healthcare Administration, Business, Health Information Management, or related field). Some organizations accept equivalent experience.
• Experience: 2+ years of experience in provider credentialing, enrollment, or similar role (in a medical billing, RCM, or healthcare setting).
• Knowledge / Technical Skills:
• Familiarity with CAQH, NPPES, PECOS, payer portals, credentialing software/platforms.
• Understanding of commercial & government payers (Medicare, Medicaid) credentialing rules.
• Strong knowledge of medical licensure, board certification, education verification, regulatory compliance.
• Proficiency in MS Office (Excel, Word, Outlook).
• Skills / Competencies:
• Strong attention to detail, organizational skills, and ability to manage multiple credentialing tracks simultaneously.
• Excellent written and verbal communication skills.
• Analytical and problem-solving mindset.
• Ability to work independently and interface with multiple stakeholders.
• Discretion and confidentiality in handling provider data.
• Desired / Optional:
• Certification such as CPCS (Certified Provider Credentialing Specialist) or CPMSM.
• Experience with multi‑state credentialing or large group practices.
• Experience with medical billing, claims, or revenue cycle functions.
• Knowledge of HIPAA or healthcare compliance standards.

Working Conditions / Schedule

• This role is generally in office or hybrid/remote (depending on the organization).
• May require working non‑standard shifts (e.g. night shift) if supporting international clients or off‑hours payer windows.
• Keyboard / computer work, calls, email communications.
• Occasional high volume / urgency periods requiring extra effort to meet credentialing deadlines.

Key Performance Indicators (KPIs)

• Turnaround time for credentialing submissions / approvals
• Percentage of credentialing applications approved without rework
• Number of credentialing backlog / pending items
• Accuracy rate (errors in credentialing files)
• Provider uptime (minimizing provider downtime due to credentialing issues)

Job Type: Full-time

Pay: Rs50, Rs80,000.00 per month

Work Location: In person