Provider Operations Specialist

NourishedRx•Stamford, CT

About The Position

The Provider Operations Specialist supports the operational and administrative functions of NourishedRx’s provider network and Fee-for-Service (FFS) business. The role manages provider credentialing and payer enrollment, claims coding and billing, and ongoing provider data maintenance. Working with internal teams, healthcare providers, insurance companies, and external vendors, the specialist helps ensure providers are appropriately credentialed, payer records are accurate and current, and services are billed accurately and on time. This is a hands-on role in a fast-paced startup environment. It requires strong organizational skills, attention to detail, problem-solving ability, flexibility, and ownership of varied operational responsibilities. The specialist works independently, manages multiple priorities, and helps develop and improve processes as the company grows. Interest in using AI and automation to improve operational efficiency is important.

Requirements

Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred; equivalent relevant experience will be considered.
2–4 years of experience in healthcare operations, provider credentialing, payer enrollment, medical billing, or revenue cycle management.
Familiarity with professional healthcare claims (CMS-1500) and commercial and/or government payer billing requirements.
Familiarity with provider credentialing, NPI registration, payer enrollment, and claims submission processes.
Strong organizational skills and attention to detail, with the ability to manage multiple priorities and deadlines.
Working knowledge of healthcare provider credentialing, payer enrollment, and medical billing processes.
Strong problem-solving skills and the ability to independently research and resolve issues.
Excellent written and verbal communication skills, including the ability to work effectively with providers, payers, vendors, and internal teams.
Proficiency with Microsoft Office and/or Google Workspace.
Ability to work independently while collaborating effectively across departments.
Comfort working in a fast-paced, evolving startup environment.
Self-starter willing to take ownership, adapt to changing priorities, and help build processes as the organization grows.
Experience using AI tools or a demonstrated ability and interest in learning how to apply AI to automate processes, develop tools, and improve operational efficiency.
Willingness to obtain additional training in Registered Dietitian claims coding and payer-specific billing requirements.

Nice To Haves

Experience with professional medical billing and coding, including CPT, HCPCS, and ICD-10.
Experience working with commercial health plans and/or government healthcare programs, including Medicare and Medicaid.
Experience billing nutrition or Medical Nutrition Therapy (MNT) services.
Experience working with payer portals, claims management systems, and provider databases.

Responsibilities

Manage provider credentialing and enrollment with commercial health plans, Medicare, Medicaid, and other payer networks.
Prepare, complete, and submit credentialing and enrollment applications for individual providers and organizational entities.
Track application status, follow up with payers, and resolve outstanding requests and enrollment issues.
Maintain provider credentialing files, including licenses, certifications, malpractice coverage, NPI information, and other required documentation.
Monitor expiration dates and manage recredentialing, license renewals, and ongoing requirements.
Coordinate with providers to obtain required information and documentation.
Review, code, prepare, submit, and track Fee-for-Service healthcare claims.
Apply CPT/HCPCS and ICD-10 diagnosis codes based on provider documentation and applicable payer billing guidelines.
Ensure claims meet payer-specific billing requirements, including provider identifiers, place of service, modifiers, and other applicable billing information.
Monitor claim status and work with internal teams and billing vendors to resolve rejections, denials, and payment discrepancies.
Manage claims corrections, resubmissions, and appeals as appropriate.
Monitor outstanding claims and support timely follow-up to ensure appropriate reimbursement.
Maintain accurate billing records and documentation.
Identify recurring billing issues and recommend improvements to claims processes, coding accuracy, and reimbursement.
Maintain accurate provider records across internal systems, payer portals, billing platforms, and other databases.
Manage updates to provider demographic and enrollment information, including addresses, practice locations, NPI numbers, tax identification information, and licenses.
Ensure provider information is consistent across payer systems and internal platforms.
Track provider participation status, effective and termination dates, and payer network affiliations.
Coordinate provider additions, changes, and terminations with payers and internal departments.
Conduct periodic reviews to identify and correct discrepancies in provider data.
Develop and maintain tracking tools, reports, and documentation for credentialing, enrollment, billing, and provider data activities.
Identify opportunities to streamline processes, improve accuracy, and increase operational efficiency.
Help establish and maintain standard operating procedures as the organization grows.
Collaborate with Finance, Clinical Operations, Technology, and other internal teams to support provider operations.
Coordinate with external billing, credentialing, and other operational vendors as needed.
Assist with special projects and other operational responsibilities as business needs evolve.
Identify opportunities to use AI tools and automation across provider operations, credentialing, payer enrollment, claims processing, and data maintenance.
Help develop, implement, and maintain AI-enabled tools and processes that reduce manual work, improve accuracy, and increase operational efficiency.
Explore and test emerging AI tools and technologies for practical day-to-day applications.
Collaborate with Technology and other internal teams to translate operational needs into automated solutions.
Help build scalable AI-enabled processes while maintaining appropriate data security, privacy, and compliance standards.
Maintain confidentiality and handle provider and patient information in accordance with applicable HIPAA requirements and company policies.
Demonstrate commitment to NourishedRx’s mission and values and flexibility in supporting broader operational needs.