Credentialing Specialist

Access Supports•Middletown, NY

1d•$28 - $30

About The Position

The Credentialing Specialist is responsible for the coordination, facilitation, and maintenance of provider credentialing, enrollment, and re-enrollment with Medicaid, Medicare, and commercial payors across medical, behavioral health, and other services. This role ensures providers are accurately enrolled, maintained in CAQH, and fully credentialed to support timely billing and compliance. Working in close collaboration with the Revenue Cycle, Payor Contracting, and Patient Accounts teams, this position helps develop strategic approaches to enrollment and reimbursement optimization. The Associate also liaises with Legal and Compliance to ensure contract accuracy and alignment with regulatory requirements.

Requirements

Minimum 3 years of relevant experience in healthcare, focusing on provider enrollment, credentialing, and payor contracting in a fast-paced environment.
Detail-oriented with excellent time management and organizational skills.
High level of accuracy and compliance awareness.
Strong interpersonal, written, and verbal communication skills.
Proactive problem-solving ability with strong judgment and discretion.

Nice To Haves

Experience with major health plans and Independent Practice Associations (IPA’s) (e.g., Cigna, UHC, Anthem, CBHS, Carelon).
Proficiency in interpreting and managing healthcare contract terms.
Knowledge of behavioral health payor requirements and credentialing.

Responsibilities

Manage timely and accurate provider enrollment with Medicaid, Medicare, and commercial payors.
Initiate credentialing and enrollment protocol with new hires and internal staff
Perform thorough checks of healthcare excluded provider sanction lists, including the OIG, OMIG, SAMS.gov, etc., to verify the eligibility of providers for employment and participation in government healthcare programs
Ensure compliance with CAQH profile creation, attestation, and ongoing maintenance for all credentialed providers.
Perform provider and location setup and ongoing maintenance in internal and external systems.
Facilitate re-credentialing and Medicare/Medicaid revalidations, ensuring continuity of billing and compliance.
Maintain and update critical enrollment documentation: NPI creation and maintenance CAQH creation and enrollment Provider professional licensure and COI (Certificate of Insurance) updates Roster management for delegated contracts (e.g., CBHS) Demographic updates and practice location changes Data validation responses from payors/internal departments
Conduct monthly provider roster updates and license verifications.
Maintain updated spreadsheets, databases, and trackers to support IPA affiliations, state requirements, and internal reporting.
Participate in ongoing education and updates (e.g., CMS, PECOS, Medicaid) and provide summaries and process improvement recommendations.
Support Billing, QA, HR, and other departments on credentialing/enrollment matters.
Ensure timely submission and tracking of all credentialing documentation for audits or regulatory reviews (e.g., NPDB, malpractice checks).
Coordinate and support contract management with all commercial payors across medical and behavioral health services.
Assist in the negotiation, analysis, and execution of contracts, ensuring favorable terms and alignment with internal revenue strategies.
Track contract performance and recommend improvements to optimize revenue and reduce denials.
Ensure accurate documentation and dissemination of contract information to internal stakeholders.
Collaborate with Revenue Cycle to streamline contract-to-payment workflows.
Lead efforts to manage and support specialized programs that improve retention, such as HRSA enrollment and maintenance, NPPES, and student loan forgiveness.
Complete documentation timely and accurately to ensure program compliance
Participate in cross-functional meetings to align credentialing and contracting with broader operational goals.
Assist with regulatory, accreditation, and managed care audits involving credentialed providers.
Work with Legal, Compliance, and leadership to implement new or updated contract strategies.
Provide support for internal audits, payer inquiries, and special projects as assigned.