Enrollment Provider & Credentialing Consultant

Solutions Technology / STI Health & Wellness•Odenton, MD

About The Position

This is an independent contractor role. The Insurance Provider Enrollment and Credentialing Specialist manages the administrative process of enrolling healthcare providers into commercial and government health insurance networks. This role conducts comprehensive background verifications to ensure all clinical staff meet regulatory, licensing, and accreditation standards. This vital role ensures clinicians are legally permitted to practice, properly affiliated with commercial and governmental payers, and authorized to submit claims for patient care. The Specialist acts as the primary liaison between clinicians, medical billing teams, and health insurance payers to ensure uninterrupted reimbursement for patient care.

Requirements

High school diploma or GED required
Minimum of 2–4 years of direct experience in medical credentialing and payer enrollment.
Hands-on experience using CAQH ProView, NPPES, and electronic medical record (EMR) software.
Deep understanding of NCQA and Joint Commission credentialing guidelines and compliance standards.
Exceptional attention to detail, strong organizational skills, and excellent written and verbal communication abilities.

Nice To Haves

bachelor’s degree in healthcare administration or a related field preferred.
Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) designation.
Established relationships or familiarity with regional commercial health plan provider relations departments.

Responsibilities

Verify provider medical licenses, board certifications, DEA registrations, education, and malpractice insurance.
Compile, complete, and submit detailed payer applications, track them to ensure completion, and resolve issues that prevent a provider from gaining "in-network" status with commercial insurance plans.
Obtain and manage practice locations and provider rosters.
Enroll individual clinicians and group practice in: Tricare, BCBS CareFirst, AETNA, CIGNA, United Healthcare, and other commercial payers as needed.
Update and maintain accurate provider profiles in national databases and registries including CAQH and NPPES.
Monitor the status of pending applications with payers to ensure timely network approval and prevent credentialing gaps.
Respond to payer request for additional information.
Ensure compliance with payer and regulatory requirements.
Track expiration dates for provider licenses, certificates, and insurances to ensure continuous compliance.
Maintain enrollment records and approval dates.
Proactively update files and renew applications to maintain compliance with changing state, federal (CMS), and accrediting (NCQA/TJC) regulations.
Manage the routine re-credentialing and revalidation processes mandated by insurers and regulatory bodies.
Investigate and resolve enrollment delays, provider data errors, and credentialing-related billing rejections.
Partner with HR, legal, clinicians, and billing/coding to streamline provider onboarding.
Work with payer representatives during the contracting process.
Ensure contracts are executed and effective dates are recorded.
Track reimbursement schedules and network participation status.