MEDICAL CREDENTIALING SPECIALIST

New Horizon Medical Solutions•Las Vegas, NV

2d•$46,000 - $60,000•Onsite

About The Position

The Medical Credentialing Specialist is responsible for managing and maintaining the credentialing, re-credentialing, and payer enrollment process for healthcare providers, ensuring compliance with all regulatory, accreditation, and payer requirements. This role verifies provider qualifications, licenses, and certifications in a timely and accurate manner, maintains provider data across industry platforms (CAQH, NPPES, PECOS), tracks expirables proactively, and serves as the primary point of contact for providers on credentialing status — safeguarding the organization’s and its clients’ ability to bill and deliver care without interruption.

Requirements

High school diploma or GED required.
2+ years of credentialing and/or payer enrollment experience in a healthcare setting (multi-specialty or hospital preferred).
Hands-on familiarity with CAQH, NPPES, PECOS, and payer enrollment processes for Medicare, Medicaid, and commercial plans.
Proficiency in Microsoft Office Suite and credentialing software.
Strong attention to detail and organizational skills; ability to manage high volumes of time-sensitive applications.
Excellent written and verbal communication with providers, payers, and internal departments.
Ability to manage multiple priorities and deadlines in a fast-paced environment.
Discretion and confidentiality in handling sensitive provider and organizational information.

Nice To Haves

Associate’s or Bachelor’s degree.
NAMSS Certified Provider Credentialing Specialist (CPCS) — the industry-standard credential — or CPMSM; or actively pursuing certification once eligible.
Experience with credentialing platforms such as MedTrainer, CredentialStream, or Modio.
Knowledge of NCQA credentialing standards and delegated credentialing arrangements.

Responsibilities

Process initial credentialing and re-credentialing applications for physicians, advanced practice providers, and other licensed professionals.
Perform primary source verification of education, training, licensure, board certification, work history, malpractice history, and other credentials.
Maintain up-to-date provider files and profiles in accordance with organizational, state, federal, and payer requirements.
Prepare and submit credentialing/enrollment packets to Medicare, Medicaid, and commercial payers; maintain follow-up until approval is confirmed.
Create and maintain provider records in CAQH, NPPES, and PECOS; complete attestations and keep profiles current.
Coordinate linkage of providers and TINs to payer portals to enable claims submission and prior authorization access.
Monitor and track license, certification, DEA, and insurance expiration dates; initiate renewals proactively.
Ensure all providers meet compliance standards set by regulatory agencies and accrediting bodies (e.g., NCQA standards).
Stay informed on changes to credentialing regulations and payer requirements.
Maintain accurate, organized, and confidential credentialing records in credentialing software (e.g., MedTrainer or comparable platforms).
Generate reports on credentialing status, expirables, and compliance metrics for leadership review.
Serve as primary point of contact for providers regarding credentialing status; assist with audits and site visits as needed.