Payer Credentialing Specialist

The Payer Credentialing Specialist at Medical Associates Plus is responsible for managing the credentialing and re-credentialing process for healthcare providers with insurance payers, ensuring compliance with all regulatory and accreditation standards. This role involves submitting and tracking applications, maintaining up-to-date provider records, and coordinating with insurance companies to resolve any credentialing issues. The specialist will also verify provider credentials, monitor expirations, and ensure timely renewals to prevent disruptions in reimbursement. Strong attention to detail, organizational skills, and the ability to navigate payer requirements are essential for success in this role.

Responsibilities

• Manage the credentialing and re-credentialing process for healthcare providers with insurance payers.
• Prepare, submit, and track credentialing applications to ensure timely approvals.
• Maintain and update provider records, including licenses, certifications, and contracts.
• Verify provider credentials and ensure compliance with payer requirements, state regulations, and accreditation standards.
• Monitor expiration dates for credentials, certifications, and contracts, ensuring timely renewals.
• Communicate with insurance companies, providers, and internal teams to resolve credentialing issues.
• Ensure providers are enrolled and linked correctly with payers to avoid disruptions in reimbursement.
• Maintain a database of credentialing documentation and ensure all records are accurate and up to date.
• Assist in audits by preparing and providing necessary credentialing documentation.
• Stay informed about changes in payer policies, credentialing regulations, and industry best practices.
• Collaborate with billing and revenue cycle teams to address any credentialing-related payment issues.
• Generate reports on credentialing status, upcoming expirations, and application progress.

Qualifications

• Education & Experience:
  • Associates or Bachelors degree in healthcare administration, business, or a related field preferred.
  • Minimum of 2 years of experience in payer credentialing, provider enrollment, or a related healthcare administrative role.
• Skills & Knowledge:
  • Strong understanding of healthcare credentialing, provider enrollment, and payer requirements.
  • Familiarity with Medicare, Medicaid, and commercial insurance credentialing processes.
  • Proficiency in credentialing software and healthcare databases (e.g., CAQH, PECOS).
  • Knowledge of HIPAA regulations and compliance standards.
  • Excellent attention to detail and organizational skills.
  • Strong problem-solving abilities and the ability to manage multiple tasks simultaneously.
  • Effective communication and interpersonal skills for interacting with providers, insurance companies, and internal teams.
  • Proficiency in Microsoft Office Suite (Word, Excel, Outlook) and ability to learn new systems.
• Other Requirements:
  • Ability to work independently and meet deadlines in a fast-paced environment.
  • Strong analytical and data management skills.
  • Commitment to maintaining confidentiality and handling sensitive information responsibly.