Credentialing & Enrollment Representative

Medusind•CA, CA

About The Position

Under the direction of the Provider & Enrollment and Contracts Manager, the Credentialing & Enrollment Representative evaluates, analyzes, and coordinates all aspects of credentialing and recredentialing for clinical providers—including Medical, Dental, Optometry, and Behavioral Health—and clinics with participating health insurance plans. The role completes and tracks provider and clinic enrollment and recredentialing, maintains accurate credentialing data, and supports timely processing in accordance with applicable standards, policies, and timelines. The representative monitors files for completeness, accuracy, quality, and compliance; identifies and resolves discrepancies that could affect credentialing or enrollment; and provides updates on credentialing and health plan enrollment. The role communicates and collaborates with providers, liaisons, medical staff leadership, Administration, colleagues, management, and health plans, while proactively identifying problems and contributing to solutions.

Requirements

A minimum of 2 years of full-time experience in all facets of credentialing, including interactions with healthcare providers.
Experience with Medicare, Medi-Cal, Managed Care, and Commercial insurance.
Proficiency in enrollment terminology.
Strong knowledge of Federally Qualified Health Centers (FQHCs) and Community Health Centers (CHCs).
Strong ability to collaborate with cross-functional teams.
High level of accuracy and ability to establish and maintain priorities in a fast-paced environment.
Strong knowledge of Microsoft Excel, Word, and Outlook.
Ability to adapt to changes in regulations, technologies, and industry trends.
Ability to communicate clearly, take initiative, and problem-solve.

Nice To Haves

Bachelor’s degree in Healthcare Administration, Business, Finance, or a related field.

Responsibilities

Complete accurate health plan enrollment applications and submit them to payors in a timely manner.
Apply knowledge of health plans, including CAQH, Medicare, Medicaid, Managed Care, and Commercial Plans.
Determine recredentialing dates and complete recredentialing for providers and clinic groups with appropriate health plans.
Maintain enrollment data and follow-ups with health plans in centralized spreadsheets for each client.
Ensure CAQH profiles are created and updated quarterly.
Enter, update, and maintain provider application data in the credentialing database, ensuring accuracy and compliance with internal policies and procedures.
Keep provider demographic information and NPPES information up to date.
Participate in agenda preparation meetings and client calls.
Electronically prepare, track, and follow up on verifications for high-volume processing of provider applications in accordance with credentialing standards, procedures, and timelines.
Monitor files for completeness and accuracy and review documentation for compliance with quality standards, accreditation requirements, and applicable policies.
Identify, analyze, and resolve information issues or discrepancies that could adversely affect practitioner credentialing and enrollment.
Provide feedback and updates regarding credentialing and health plan enrollment for providers and clinics.
Communicate clearly and respond in a timely manner to providers, their liaisons, medical staff leadership, and Administration.
Communicate regularly with colleagues, management, health plans, and providers, and attend internal and client meetings in a timely manner.
Take initiative and respond proactively to identified issues.
Problem-solve credentialing issues, develop solutions, and report to management when necessary.
Anticipate and identify potential issues before they occur.
Maintain current and accurate provider and credentialing records, including initial and recredentialing data.