Medical Credentialing Specialist

Claim.MD•Pecos, NM

3d•$76,000 - $86,000•Remote

About The Position

The Medical Credentialing Specialist is responsible for researching, documenting, and maintaining the operational and regulatory requirements governing provider credentialing and enrollment across commercial, government, and managed care payers. This role manages credentialing resources and operational documentation that support consistent, accurate, and compliant provider enrollment activities. Operating at the intersection of credentialing operations, payer requirements, regulatory compliance, and process management, the Medical Credentialing Specialist serves as a subject matter expert on provider credentialing standards and operational practices. This role evaluates credentialing requirements, monitors regulatory and payer changes, maintains operational documentation, and partners with internal stakeholders to support consistent, efficient, and compliant credentialing operations.

Requirements

Thorough understanding of provider credentialing, enrollment, revalidation, and payer participation requirements across commercial and government health plans.
Experience utilizing credentialing platforms including CAQH ProView, PECOS, NPPES, state Medicaid portals, and commercial payer enrollment systems.
Understanding of CMS regulations, credentialing standards, payer enrollment requirements, and healthcare regulatory frameworks affecting provider participation.
Ability to interpret complex payer requirements, regulatory guidance, and operational documentation and translate findings into clear internal resources.
Ability to organize, maintain, and continuously improve comprehensive credentialing documentation supporting operational consistency and audit readiness.
Ability to evaluate complex credentialing requirements, identify operational implications, and recommend practical, compliant solutions.
Ability to identify process improvements, standardize documentation, and support scalable credentialing operations.
Communicates effectively with internal teams, payer representatives, and regulatory organizations while supporting cross-functional initiatives.
Understands the importance of HIPAA, PHI protection, credentialing documentation integrity, and regulatory compliance.
A high school diploma, GED, or equivalent is required.
A minimum of five (5) years of progressive experience in medical credentialing, payer enrollment, or healthcare revenue cycle operations, preferably within: A medical clearinghouse, A billing or revenue cycle management (RCM) firm, A multi-specialty provider group or managed care organization.
Demonstrated experience managing provider credentialing workflows using systems such as: CAQH ProView, PECOS, NPPES, and commercial payer portals, Tracking systems for expiration dates, revalidation, or regulatory audits.
Working familiarity with national and state-level payer enrollment standards, including: Medicare/Medicaid guidelines (CMS), State-by-state enrollment protocols and revalidation timelines, Internal auditing, reporting, and compliance support documentation.
Proven experience partnering with internal departments (e.g., Development, Privacy & Compliance) and external stakeholders (e.g., payers, regulatory bodies) to solve complex credentialing issues and improve processes.
Prior success in a remote or distributed work environment with the ability to independently manage time, communication, and output expectations across multiple projects or stakeholders.

Nice To Haves

Associate or Bachelor’s degree in Healthcare Administration, Health Information Management, Business Administration, or a related field preferred, or equivalent professional experience.
Experience supporting credentialing operations within a healthcare clearinghouse, revenue cycle management organization, managed care organization, or multi-specialty provider group.
Experience maintaining or improving standard operating procedures (SOPs), operational documentation, training materials, or process guides.
Experience working directly with payer credentialing departments, provider enrollment teams, or regulatory organizations.
Experience supporting credentialing audits, compliance initiatives, or quality improvement programs.
Working knowledge of state-specific provider enrollment requirements and credentialing variations across multiple jurisdictions.

Responsibilities

Research, interpret, and maintain provider credentialing and enrollment requirements for commercial, Medicare, Medicaid, and other payer organizations.
Analyze payer credentialing policies, provider manuals, enrollment guides, and regulatory resources to identify operational requirements, workflow considerations, and business impacts.
Manage credentialing documentation, operational references, and internal knowledge resources that support consistent business practices.
Organize credentialing resources, including payer requirements, documentation standards, operational guidance, timelines, and reference materials.
Periodically review credentialing resources to ensure information remains current, accurate, and aligned with evolving payer requirements and regulatory guidance.
Maintain documentation addressing payer-specific credentialing requirements, enrollment prerequisites, revalidation schedules, and submission processes.
Evaluate payer-specific credentialing requirements to identify operational differences, documentation needs, and workflow impacts.
Standardize and enhance operational reference materials outlining payer workflows, documentation requirements, processing expectations, and operational considerations.
Ensure credentialing documentation remains accurate, organized, and audit-ready.
Monitor federal, state, and payer-specific regulatory changes affecting provider credentialing and enrollment.
Evaluate regulatory updates for operational impact and recommend appropriate documentation or process revisions.
Maintain working knowledge of CMS guidance, state Medicaid enrollment requirements, CAQH processes, NPPES, PECOS, and other applicable credentialing standards.
Support internal compliance initiatives by ensuring credentialing documentation accurately reflects current regulatory expectations.
Evaluate credentialing processes to identify opportunities for improved consistency, efficiency, and operational effectiveness.
Maintain and refine operational documentation, workflow resources, reference guides, and supporting materials related to credentialing activities.
Recommend enhancements to credentialing processes, documentation standards, and operational practices.
Support continuous process improvement initiatives that strengthen operational quality, documentation consistency, and business efficiency.
Promote standardized operational practices that support consistent credentialing activities across the organization.
Partner with Payer Relations, Support Services, Development, Privacy & Compliance, and other internal stakeholders to ensure credentialing requirements are accurately reflected within operational processes and documentation.
Collaborate on initiatives involving provider onboarding, payer operational changes, credentialing activities, and business process improvements.
Provide credentialing subject matter expertise to support operational decisions, documentation updates, and workflow refinement.
Promote alignment across departments by supporting consistent credentialing practices and documentation standards.
Serve as an internal subject matter expert regarding provider credentialing standards, payer enrollment requirements, and industry best practices.
Interpret complex credentialing requirements and translate them into practical operational guidance and documentation.
Maintain awareness of emerging credentialing trends, regulatory developments, and evolving payer practices.
Provide recommendations that strengthen operational consistency, documentation quality, and credentialing readiness.