Credentialing Specialist II

Job Description:

Summary:
We are seeking a highly experienced and detail-oriented Senior Credentialing Specialist to manage the full credentialing lifecycle for our diverse network of healthcare providers. The ideal candidate will possess extensive expertise in provider credentialing, including a strong working knowledge of PECOS, CAQH, Medicare, Medicaid, and commercial payer applications across multiple states. This role demands a proactive, self-directed individual who can work efficiently both independently and collaboratively within a team, ensuring timely and accurate credentialing to maintain provider network participation, optimize revenue cycle management, and uphold compliance.

Key Responsibilities:

• Comprehensive Credentialing Management:
  • Manage the end-to-end credentialing and re-credentialing processes for physicians, nurses, therapists, and other allied health professionals.
  • Verify and maintain provider credentials, ensuring all required documentation and certifications are up-to-date and compliant with federal, state, and payer regulations.
  • Proactively track license and certification expirations, initiating timely renewal processes.
• Application Expertise:
  • Prepare and submit accurate credentialing applications to Medicare, Medicaid, and commercial payers across all states.
  • Demonstrate proficiency in utilizing PECOS for Medicare enrollment and maintenance.
  • Proficient in CAQH application and maintenance.
  • Navigate and resolve complex payer-specific credentialing requirements.
• Verification and Data Management:
  • Conduct thorough primary source verification of provider credentials, including education, training, licensure, certifications, and professional experience.
  • Accurately input and maintain provider data in online credentialing databases and systems.
  • Maintain accurate and up-to-date provider credentialing files and databases.
• Communication and Collaboration:
  • Serve as a primary point of contact for healthcare providers, insurance companies, and regulatory bodies, effectively resolving credentialing inquiries and issues.
  • Collaborate with internal departments, including billing, compliance, and human resources, to ensure seamless provider enrollment and credentialing processes.
  • Conduct weekly follow up on all pending applications and documents to ensure timely credentialing.
  • Keep supervisors, management, and providers informed of the status of new/revised or pending provider numbers, effective dates, plans, etc.
• Accountability and Reporting:
  • Take individual responsibility for the credentialing of assigned providers, ensuring accuracy and timeliness.
  • Generate and maintain reports related to credentialing status, upcoming renewals, and re-credentialing deadlines.
  • Address and resolve credentialing discrepancies or issues promptly to prevent delays in provider services.

Qualifications:

• Extensive experience in healthcare provider credentialing, including Medicare, Medicaid, and commercial payer applications across multiple states.
• Strong working knowledge of PECOS.
• Strong working knowledge of CAQH.
• Proven ability to manage the full credentialing lifecycle.
• Excellent organizational, communication, and problem-solving skills.
• Ability to work independently and collaboratively within a team

Please Note: -

Work from Office Only (Location: -Vadodara, Gujarat)

US/Night Shift.

Qualifacts is an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees.