Credentialing Specialist (Sr. Provider Payer Enrollment)

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.