Medical Staff Credentialing and Provider Enrollment Coordinator

Concord Hospital•Concord, NH

19d

About The Position

The Medical Staff Credentialing and Provider Enrollment Coordinator is responsible for executing all aspects of medical staff credentialing and provider enrollment to ensure compliance with organizational policies, Medical Staff Bylaws, and regulatory and accreditation standards. This role processes appointments, reappointments, privileging requests, temporary privileges, leave of absences, staff category changes, name changes, resignations, and all provider enrollment, re-verification, and terminations with federal, managed care, and other third-party payors. The coordinator partners with physician and administrative leaders to develop, draft, and maintain clinical privileging criteria, ensures timely and accurate enrollment activities, and supports organizational readiness for reimbursement, audits, accreditation, and regulatory reviews. Additionally, the role maintains up-to-date knowledge of regulatory requirements, applies best practices to credentialing and enrollment processes, and assists with accreditation and regulatory survey preparation.

Requirements

High School diploma or GED, and a minimum of three years related experience.
Minimum of three years related experience and proficiency in Microsoft Office applications, including Word and Excel; experience with credentialing systems, CAQH, and web portals for insurance enrollment; knowledge of billing; familiarity with accreditation organizations and their standards; and a high level of data-entry accuracy.

Nice To Haves

Prior experience in Medical Staff Credentialing and Provider Enrollment is strongly preferred.

Responsibilities

Manage and perform comprehensive credentialing and privileging processes for practitioners, including initial applications, reappointments, temporary privileges, leave of absence requests, additional privilege requests, staff category changes, and resignations.
Conduct critical analysis of all credentialing and privileging applications to verify eligibility, flag areas of concern, and resolve discrepancies in alignment with organizational standards.
Maintain accurate and up-to-date internal and electronic files, databases, and tracking logs for credentialing, privileging, and provider enrollment, ensuring integrity and proper documentation throughout the process.
Provide administrative and meeting support for the Credentials Committee, including preparation, documentation, and follow-up of actions and decisions.
Process and maintain all aspects of provider enrollment and re-enrollment with federal, state, and commercial payors for practitioners and institutional groups, including initial enrollment, revalidations, updates, terminations, including provider directory and CAQH review and updates.
Ensure timely and accurate submission of enrollment applications, re-enrollment forms, and supporting documentation.
Respond to and resolve issues related to provider network participation, including eligibility, denials of services, and reimbursement discrepancies, acting as a liaison between providers, hospital staff, and payor representatives.
Develop and maintain positive relationships with internal and external stakeholders, including practitioners, leadership, payors, government, and regulatory agencies, and ensure the timely resolution of inquiries and complex issues.
Ensure compliance with all applicable regulatory, accreditation, and payor standards, including CMS, NCQA, and other federal and state requirements.
Recommend and help implement process improvements and best practices to enhance operational efficiency and compliance.
Assist with accreditation and regulatory survey readiness for credentialing functions.
Provide backup support to colleagues and perform other duties as assigned.