Provider Enrollment and Credentialing

Nevada Regional Medical Center•Nevada, MO

About The Position

The Provider Enrollment Specialist and Medical Staff Credentialing role is part of the Nevada Regional Medical Center Quality Department. It manages end-to-end credentialing, re-credentialing, privileging, and payer enrollment for physicians, advanced practice providers, and allied health professionals. The role operates within NRMC’s quality framework, aligned with CIHQ and state and federal regulatory standards, and helps ensure medical staff maintain compliant credentials and active billing and network statuses. The position manages initial appointments, reappointments, and expedited credentialing; verifies credentials through primary sources; processes clinical privilege requests; and prepares files for the Medical Staff Credentials Committee and Board of Directors. It also coordinates enrollment with Medicare, Missouri Medicaid (MO HealthNet), commercial payers, and managed care organizations, maintaining provider profiles in CAQH ProView, NPPES, and PECOS. The role tracks applications through active network status, resolves payer requests, and coordinates with Patient Financial Services and Billing. Additional duties include monitoring expiration dates for licenses and other provider credentials, supporting regulatory compliance, audits, surveys, and quality reviews, and reporting provider status changes to appropriate leadership, committees, and health plans. The role requires confidentiality, accuracy, effective communication, prioritization, and multitasking in a healthcare environment. Base wage starts at $22, with increases based on experience; the position is incentive eligible.

Requirements

High school diploma or equivalent required.
Minimum of 2–3 years of direct experience in medical staff credentialing, privileging, and/or provider enrollment within a hospital, healthcare system, or managed care environment.
Strong working knowledge of NCQA, CMS, and CIHQ accreditation standards.
Ability to communicate clearly and effectively with all levels.
Ability to complete competency CPR and First Aid.
Ability to prioritize and complete multiple tasks simultaneously.
Effective oral and written communication skills.
Exceptional attention to detail and a high degree of accuracy with sensitive data.
Proficiency with credentialing software platforms, CAQH, PECOS, and electronic medical record and office applications.
Ability to interface professionally with physicians, executive leadership, and external agency representatives.
Strong time-management capabilities and ability to multitask in a fast-paced healthcare environment.

Nice To Haves

Associate’s or Bachelor’s degree in healthcare administration, business, or a related field is strongly preferred.
Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) through NAMSS is highly preferred, or a commitment to obtaining certification within an agreed timeframe.

Responsibilities

Manage initial appointments, reappointments, and expedited credentialing for Medical Staff and Allied Health Professionals in accordance with NRMC bylaws, rules, regulations, and accrediting standards.
Conduct primary-source verification of licensure, education, training, board certification, work history, malpractice history, and peer references.
Process clinical privilege requests in alignment with training, competency, and hospital scope-of-practice guidelines.
Prepare credentialing files and summary packets for the Medical Staff Credentials Committee and Board of Directors.
Maintain confidentiality of peer review and provider credentialing records.
Coordinate and manage provider enrollment and contract setup with Medicare, Missouri Medicaid (MO HealthNet), commercial insurance payers, and managed care organizations.
Maintain provider profiles in CAQH ProView, NPPES, and PECOS, including regular re-attestations and accurate data.
Track enrollment applications from submission through active network status and resolve payer discrepancies or information requests.
Coordinate with Patient Financial Services and Billing to support newly onboarded providers.
Monitor expiration dates for professional licenses, DEA registrations, controlled substance certificates, malpractice insurance certificates of insurance, and life support certifications, and complete tracking workflows ahead of deadlines.
Ensure compliance with CMS conditions of participation, CIHQ accreditation standards, and state regulations.
Assist with internal audits, regulatory surveys, and quality reviews related to medical staff governance and credentialing data.
Report provider status changes, including sanctions, loss or restriction of privileges, and license actions, to appropriate administrative leadership, credentialing committees, and contracted health plans.