Insurance Credentialing Specialist

Thundermist Health Center

1d•Onsite

About The Position

The Insurance Credentialing Specialist is responsible for managing all components of provider and facility insurance credentialing, re-credentialing, and payer enrollment to ensure accurate, timely participation in health plans. This role supports Licensed Independent Practitioners (LIPs) and works closely with internal departments, external payers, and regulatory bodies to maintain compliance, reduce claim denials, and optimize operational efficiency. This role is separate and distinct from provider professional credentialing and privileging.

Requirements

High school diploma and 2-3 years prior office/administrative experience in a busy setting, preferably in Credentialing or Human Resources, performing a variety of functions.
Excellent interpersonal skills required to interact/communicate with all levels of staff, as well as external agencies and individuals.
Must possess strong, accurate data entry skills
Must be detail-oriented and have strong organizational skills.
Ability to manage multiple assignments and priorities
Ability to maintain confidentiality of sensitive information.
Proficient in Word; knowledge of Excel
Ability to read and interpret documents, such as credentialing instructions/applications, correspondence, policy and procedures required.
Good oral and written communication skills, including good telephone skills, required.
Willingness to engage in repeated follow-up, to obtain necessary documents or signatures

Nice To Haves

Associate or bachelor’s degree preferred; equivalent experience considered.
1–3+ years of credentialing or payer enrollment experience in a healthcare setting.
Knowledge of Medicare, Medicaid, commercial insurance plans, CAQH, NPPES, PECOS, and industry credentialing standards.
Candidates who do not meet all of the preferred qualifications are encouraged to apply.

Responsibilities

Complete initial and re-credentialing applications for providers across all payer types (commercial, Medicaid, Medicare, and managed care organizations).
Maintain up-to-date records in CAQH, NPPES/NPI Registry, PECOS, and other credentialing portals.
Manage enrollment for new practice locations, taxonomy updates, and facility-level credentials.
Understand the credentialing requirements of third-party insurers, including required payor provider training.
Submit and track payer applications, demographic updates, terminations, and revalidations.
Follow-up with providers and supervisors to ensure the timely completion of insurance credentialing paperwork/information.
Serve as a point of contact with the insurance companies/providers regarding questions or problems regarding applications as they arise. Follow up regularly on the status of pending applications.
Process quarterly payer demographic attestations and CAQH attestations to ensure provider information remains active and accurate.
Monitor and resolve payer issues, including enrollment delays, roster discrepancies, claim denials related to credentialing, and provider directory errors.
Maintain knowledge of payer-specific requirements and timelines (Medicare PECOS, Medicaid revalidations, commercial plans, etc.
Organize and maintain all credential records and files and purge records as needed.
Maintain a summary of requirements for each insurer.
Update internal databases and insurance credentialing trackers with real-time status of provider applications and enrollments.
Collaborate to provide regular reports on progress and delays associated with individual insurance credentialing to keep leadership, billing, practice management, and HR up to date.
Collaborate on managing the Centralized Credentialing Management System, including dashboards that display enrollment status, expirables, productivity impacts, and credentialing timelines.
Recommend workflow enhancements to reduce payer enrollment turnaround times and expedite onboarding.
Support implementation of new insurance credentialing systems, automation tools, and data dashboards.
Participate in audits, compliance reviews, and policy development.
Maintain cooperative relationships with other employees, clients, and the public.
Communicate effectively with staff, representatives of other agencies, and the public.
Work in cooperation with co-workers and supervisory staff.
Assist with projects as required; perform other duties as assigned.