Senior Credentialing Coordinator

VALLEY COMPREHENSIVE COMMUNITY MENTAL HEALTH CENTER INC•Morgantown, WV

4d•Onsite

About The Position

The Credentialing Coordinator reports directly to the Director of Corporate Compliance and manages all agency provider credentialing, payer enrollment, recredentialing, revalidation, and credential maintenance. This role is the central point of accountability for employees, contracted providers, organizational enrollments, and service location affiliations across all Valley HealthCare System programs. The coordinator maintains accurate records, completes applications, verifies approvals, tracks deadlines, and resolves enrollment issues in coordination with Human Resources, Finance, Program Supervisors, Billing, and Agency Leadership.

Requirements

Ability to perform Essential Duties as outlined below.
BA/BS degree in healthcare administration, business, or a related field, or an equivalent combination of education and relevant healthcare administrative experience.
At least two years of experience in provider credentialing, payer enrollment, or healthcare administration with responsibility for provider records and payer requirements.
Knowledge of credentialing, primary source verification, provider enrollment, confidentiality, and documentation practices.
Ability to manage a high-volume workload, reconcile detailed records, meet deadlines, and follow unresolved issues through completion.
Proficiency with Microsoft Excel, Word, Outlook, Teams, electronic records, and web-based payer portals.
Ability to interpret written requirements, communicate clearly, work independently, and escalate concerns appropriately.
Ability to comply with Client’s Rights and Valley’s division/departmental safety procedures.
Ability to read, write, understand, and speak the English language.
Valid Driver’s License.

Nice To Haves

Experience with West Virginia Medicaid enrollment, Medicaid managed care organizations, Medicare, commercial payers, and behavioral health provider credentialing.
Experience with CAQH, NPPES, PECOS, Gainwell, payer portals, and credentialing databases or tracking systems.
Knowledge of credentialing requirements relevant to licensed behavioral health centers, CCBHC services, CARF accreditation, and licensed and non-licensed direct service staff.
Certified Provider Credentialing Specialist (CPCS) certification or willingness to pursue certification.

Responsibilities

Manage the complete credentialing lifecycle for all agency providers, including initial credentialing, payer enrollment, recredentialing, revalidation, affiliations, changes, and termination of agency participation.
Maintain a complete inventory of employees and contracted providers across all programs and locations, including licensed practitioners, nursing staff, non-licensed direct service staff, peer recovery staff, and other roles subject to credentialing or enrollment requirements.
Maintain role-specific and payer-specific checklists identifying required documents, qualifications, enrollment prerequisites, submission methods, approval steps, and renewal deadlines. Verify applicability rather than assuming all provider categories follow the same process.
Coordinate credentialing at hire and before role, program, or location changes. Provide individualized packets, review submissions for completeness, obtain missing information, and give providers and supervisors clear due dates and follow-up instructions.
Collect and maintain applicable licenses, certifications, education and training records, work history, references, liability coverage, identification, disclosure forms, supervision documentation, and other required credentialing records.
Verify primary source verification as required by the applicable payer through Human Resources. Record the source, verification date, result, expiration date, and reviewer, and resolve any discrepancies before submission.
Coordinate with Human Resources Department to verify applicable background screening, WV CARES eligibility, APS/CPS screening, and other employment or program clearances. Track and monitor all determinations and renewal dates and promptly escalate missing, adverse, or expired results immediately.
Perform or reconcile required exclusion and sanction screenings, license status reviews, and other ongoing checks on the established schedule. Retain documentation, resolve potential matches, and immediately report confirmed adverse findings to agency Leadership.
Coordinate individual and organizational NPI applications and updates, taxonomy selection, and demographic corrections. Validate consistency among source documents, NPPES, payer records, and agency systems.
Establish and maintain authorized access to credentialing systems and payer portals. Assist providers with CAQH profiles, document uploads, payer access, updates, and timely attestations.
Prepare, submit, and track applications for WV Medicaid through Gainwell, applicable WV CHIP and Medicaid managed care plans, Medicare, commercial insurers, and other agency payers. Complete each applicable payer process and prerequisite in the required sequence.
Manage organizational and facility enrollment records, group affiliations, service location additions, demographic changes, and supporting documents. Coordinate W-9s, licenses, insurance certificates, accreditation records, ownership disclosures, and authorized signatures with responsible departments.
Prepare and validate payer rosters and bulk uploads. Confirm provider identifiers, credentials, roles, agency tax identification numbers, organizational NPIs, and authorized service locations before submission.
Track submission dates, reference numbers, outstanding requests, follow-up dates, aging, approvals, denials, and effective dates. Monitor portal messages and correspondence, respond within applicable deadlines, and pursue stalled applications through resolution.
Obtain and retain written payer approval and effective-date evidence. Distinguish application submission, credentialing approval, network participation, enrollment, and location affiliation, and verify each applicable requirement before communicating with a provider and their supervisor that they are approved to bill services.
Maintain a central provider and expiration tracker showing current credentials, payer status, approved locations, effective dates, renewal dates, missing documents, assigned follow-up owners, and supporting evidence. Reconcile records with Human Resources, supervisors, Billing and Finance Department, and payer portals on an ongoing basis.
Monitor upcoming expirations, recredentialing, revalidation, attestations, and screening renewals. Communicate with Human Resources to send advance reminders, collect updated documents, submit renewals, and escalate overdue items early enough to reduce interruptions in services or reimbursement.
Provide documented credentialing status updates to Human Resources, supervisors, scheduling staff, and Billing. Identify any restrictions and unresolved prerequisites.
Ensure Application for Privileges is current and has been authorized by leadership prior to CCRC review and approval.
Work with Billing and Finance Department to investigate credentialing-related claim denials, incorrect provider affiliations, missing effective dates, and payer record discrepancies. Obtain corrections and supporting documentation and notify the program supervisor.
Immediately escalate exclusions, suspended or expired licenses, adverse eligibility determinations, missed deadlines, denied applications, suspected inaccurate submissions, and other material risks. Track corrective actions and do not independently waive requirements or approve exceptions.
Process provider separations, transfers, and changes in credentials or practice information within applicable timeframes. Notify payers, update agency affiliations and directories, coordinate access removal, and retain termination confirmations and historical records.
Serve as the agency’s primary contact for provider credentialing and enrollment questions. Maintain professional payer relationships and a documented communication log, including written clarification of conflicting or unclear requirements.
Provide the Director of Corporate Compliance with weekly status updates and monthly summaries of pending applications, approaching deadlines, overdue documents, denials, unresolved risks, and completed enrollments. Identify any barriers that require prompt action immediately.
Monitor applicable payer instructions, enrollment notices, licensing requirements, and accreditation expectations.
Maintain secure, organized, audit-ready credentialing files with verification records, signed applications, correspondence, approvals, and historical changes.
Prepare records for payer reviews, audits, and accreditation surveys. Conduct routine credentialing file quality checks, correct data errors, and assist with investigations and corrective actions related to provider eligibility or enrollment.
Train and support providers, Human Resources, and supervisors on credentialing documentation and timelines. Complete application processing and ongoing tracking while holding providers and supervisors accountable for timely documents, signatures, and responses.
Perform other duties as assigned by the Director of Corporate Compliance.