Credentialing Process Expert (provider)

Industry & Sector:

Standardized Title:

• Manage end-to-end provider credentialing lifecycle—collect, validate, and maintain credentialing packets and provider documentation to ensure timely enrollment and network participation.
• Perform primary source verification (PSV) for licensure, education, board certification, DEA, and work history; document results and maintain audit-ready records in credentialing systems.
• Prepare and submit enrollment and re-credentialing applications to CAQH, PECOS, state Medicaid, and commercial payers; monitor application status and resolve payer requests or deficiencies.
• Maintain and reconcile provider data across directories and databases (NPI, TIN, specialty, rosters); update credentialing platforms and internal systems for accuracy.
• Track expirations, alerts, and compliance requirements; coordinate renewals and remediation to prevent gaps in provider billing or network access.
• Collaborate with provider relations, compliance, HR, and operations to implement process improvements, support audits, and meet NCQA/TJC readiness requirements.
  

Skills & Qualifications

Must-Have

• Proven experience managing provider credentialing and enrollment processes, including re-credentialing and primary source verification.
• Hands-on familiarity with CAQH ProView and PECOS payer portals.
• Experience using credentialing systems and maintaining provider databases (e.g., Cactus, symplr or equivalent).
• Strong working knowledge of NPI registry, state Medicaid enrollment, and payer-specific enrollment requirements.
  

Preferred

• Understanding of NCQA/TJC standards and audit-readiness practices for credentialing.
• Experience with verification vendors (e.g., Verisys) or advanced Excel / reporting skills for credentialing metrics and SLAs.
  

• On-site team environment with structured career paths in provider services and healthcare operations.
• Opportunities for upskilling in payer enrollment platforms and compliance frameworks.
• Competitive compensation, performance-linked incentives, and focus on operational excellence.