Credentialing Specialist

Credentialing Specialist I

Position Summary

The Credentialing Specialist I is responsible for supporting provider credentialing, enrollment, and maintenance activities to ensure timely participation with commercial, government, and managed care payers. This role manages assigned provider onboarding and enrollment processes, maintains accurate provider records, and ensures compliance with payer, regulatory, and organizational requirements.

The Credentialing Specialist I develops and applies knowledge of credentialing systems, provider enrollment processes, and healthcare operations while serving as a key point of coordination between providers, payers, practice leaders, and internal departments. The position requires strong attention to detail, organizational skills, customer service, and the ability to manage multiple priorities in a fast-paced environment.

Essential Responsibilities

• Coordinate assigned provider onboarding, credentialing, and enrollment activities from intake through approval and network participation.
• Collect, review, validate, and maintain provider demographic, licensure, certification, malpractice, and credentialing documentation.
• Create, update, and attest provider profiles within CAQH, NPPES, PECOS, and other credentialing and enrollment systems.
• Prepare, submit, and track payer enrollment applications and supporting documentation to ensure timely processing.
• Conduct routine follow-up with commercial and government payers regarding application status, deficiencies, approvals, and participation effective dates.
• Maintain accurate records of credentialing and enrollment activities within departmental databases, tracking systems, and Microsoft 365 applications.
• Utilize Microsoft Outlook, Excel, Word, Teams, SharePoint, and OneDrive to manage documentation, communication, reporting, and workflow tracking.
• Monitor enrollment milestones, pending requirements, expirations, and credentialing deadlines to support provider readiness.
• Process provider demographic updates, location changes, revalidations, and ongoing maintenance requests.
• Research and resolve enrollment discrepancies, payer issues, and documentation deficiencies while escalating complex issues as appropriate.
• Provide timely status updates and professional customer service to providers, practice leadership, and internal stakeholders.
• Ensure compliance with payer requirements, accreditation standards, regulatory guidelines, and organizational policies.
• Support departmental audits and quality assurance activities by maintaining complete and accurate provider records.
• Contribute to process improvement initiatives that enhance credentialing efficiency, data accuracy, and provider experience.
• Meet established productivity, quality, service-level, and turnaround-time expectations.

Qualifications

• Minimum of 2 years of experience in healthcare administration, credentialing, provider enrollment, or a related healthcare operations role.
• Minimum of 1 year of experience in an optometry or ophthalmology practice preferred.
• Experience with CAQH, PECOS, NPPES, payer portals, and provider enrollment systems.
• Experience using Microsoft 365 (MS365) applications, including Outlook, Excel, Word, Teams, SharePoint, and OneDrive.
• Strong understanding of healthcare operations, provider enrollment, billing, reimbursement, and payer processes.
• Excellent organizational, analytical, and problem-solving skills.
• Strong written and verbal communication skills with the ability to work effectively across departments.
• Ability to manage confidential information with a high degree of professionalism and accuracy.
• Ability to prioritize competing deadlines and maintain attention to detail in a fast-paced environment.

Core Competencies

• Attention to Detail
• Organization and Follow-Through
• Customer Service Excellence
• Written and Verbal Communication
• Accountability and Ownership
• Time Management and Prioritization
• Problem Identification and Resolution
• Microsoft 365 Proficiency
• Healthcare Operations Knowledge
• Provider Credentialing and Enrollment
• Compliance and Documentation Management
• Cross-Functional Collaboration
• Continuous Learning and Adaptability