Credentialing Specialist

Essential Duties & Responsibilities

• Complete initial provider credentialing and payer enrollment applications.
• Manage Medicare and Medicaid enrollment processes.
• Complete commercial insurance payer applications.
• Maintain and update provider CAQH profiles.
• Manage PECOS enrollment and maintenance activities.
• Complete provider recredentialing and revalidation.
• Track application status from submission through completion.
• Follow up directly with insurance companies regarding pending applications.
• Maintain provider demographic information with payers.
• Process changes involving practice locations, addresses, tax information, ownership, and provider affiliations as appropriate.
• Assist with provider additions and terminations.
• Complete group and individual provider linking/affiliation requests.
• Maintain credentialing records and supporting documentation.
• Track provider licenses, certifications, NPI information, malpractice coverage, DEA information when applicable, and other credentialing requirements.
• Monitor expiration and renewal dates.
• Respond to payer requests for additional information.
• Maintain accurate credentialing trackers.
• Document payer reference numbers, effective dates, participation status, and follow-up activity.
• Coordinate with billing staff to resolve credentialing-related claim denials.
• Escalate enrollment delays or payer issues to the Operations Manager.
• Communicate credentialing status and outstanding requirements to clients.

Government Payer Enrollment

The Credentialing Specialist should be comfortable working with:

• Medicare
• PECOS
• NPPES/NPI
• State Medicaid programs
• Medicaid Managed Care organizations
• Medicare Advantage plans
• Provider revalidation
• Group affiliations
• Practice location changes
• EFT/ERA enrollment when assigned

Commercial Credentialing

Responsibilities may include:

• Initial payer enrollment
• Network participation applications
• CAQH maintenance and re-attestation
• Recredentialing
• Provider additions
• Provider terminations
• Demographic updates
• Tax ID/group changes
• Contracting coordination
• Payer roster maintenance
• Effective-date verification

Credentialing & Billing Coordination

This position will work closely with the billing and A/R teams to identify claims affected by:

• Provider not credentialed
• Provider not linked to group
• Incorrect billing or rendering provider
• Incorrect service location
• Enrollment termination
• Revalidation issues
• Incorrect NPI or Tax ID
• Effective-date discrepancies

The Credentialing Specialist will research these issues and coordinate appropriate corrections.

Required Qualifications

• Minimum 2 years of healthcare credentialing or provider enrollment experience preferred.
• Experience with Medicare and/or Medicaid provider enrollment.
• Experience maintaining CAQH profiles.
• Familiarity with PECOS and NPPES.
• Understanding of individual and group provider enrollment.
• Experience communicating with insurance payer credentialing departments.
• Strong organizational and follow-up skills.
• Excellent attention to detail.
• Ability to manage multiple applications simultaneously.
• Strong written and verbal communication skills.
• Ability to work independently and meet deadlines.
• Proficiency with electronic payer portals and document management systems.

Preferred Qualifications

• Experience working for an RCM, credentialing, or medical billing company.
• Experience credentialing multiple healthcare specialties.
• Experience with Medicare, Medicaid, Medicare Advantage, Medicaid MCOs, and commercial insurance.
• Experience with provider revalidation and recredentialing.
• Experience with group enrollment and provider affiliations.
• Experience with payer contracting.
• CPCS, CPMSM, or related credentialing certification is a plus.
• Bilingual English/Spanish is a plus.

Performance Expectations

Performance will be evaluated based on:

• Application completion accuracy
• Application turnaround time
• Timely payer follow-up
• Credentialing completion rate
• Revalidation/recredentialing completed before deadlines
• Accuracy of provider records
• Credentialing tracker accuracy
• Responsiveness to payer requests
• Prevention of enrollment-related billing disruptions
• Client communication and service
• Documentation quality

What We're Looking For

We need someone who owns the credentialing process from application to effective date.

Submitting an application is not considered completion. The Credentialing Specialist is expected to track applications, follow up with payers, respond to requests, obtain effective dates, update internal records, and communicate completion to the appropriate teams.

The successful candidate will understand that credentialing directly affects a healthcare provider's ability to see patients, submit claims, and receive reimbursement.

Why Join AdvantixxRCM?

AdvantixxRCM provides the opportunity to work with multiple healthcare organizations, providers, specialties, and insurance payers while developing advanced expertise in provider credentialing and healthcare revenue cycle operations.

We value accuracy, accountability, organization, communication, and follow-through.

Position Summary

AdvantixxRCM is seeking an experienced Credentialing Specialist to manage provider credentialing, payer enrollment, recredentialing, revalidation, and ongoing provider maintenance for our healthcare clients.

The Credentialing Specialist is responsible for ensuring providers and healthcare organizations are appropriately enrolled and maintained with government and commercial insurance payers.

The ideal candidate is highly organized, understands healthcare payer enrollment, and can independently manage multiple providers and applications while meeting strict deadlines.