SENIOR PROVIDER ENROLLMENT AND CREDENTIALING SPECIALIST

The Senior Provider Enrollment and Credentialing Specialist at our Federally Qualified Health Center is responsible for overseeing the comprehensive enrollment and credentialing processes for all healthcare providers within our organization. This role ensures the seamless onboarding and maintenance of provider credentials and enrollment status across multiple payer networks and regulatory agencies.

Key Responsibilities

1. Provider Enrollment & Re-Enrollment
   • Coordinate and manage the end-to-end enrollment process for new and existing providers, including physicians, mid-level practitioners, and ancillary staff, across various government and commercial payers.
   • Ensure timely submission, follow-up, and resolution of all enrollment applications to minimize revenue disruptions and maintain compliance with payer guidelines.
   • Monitor renewal and re-validation processes for all provider enrollments to prevent lapses in coverage or billing privileges.
2. Credentialing & Re-Credentialing
   • Oversee initial credentialing and ongoing re-credentialing of providers, verifying all required licensures, certifications, education, training, and professional references.
   • Maintain a detailed tracking system of critical credentialing deadlines and initiate timely updates for all staff to ensure uninterrupted clinical services.
   • Collaborate with clinical leadership and compliance teams to address any discrepancies or irregularities discovered during credentialing.
3. Data Management & Documentation
   • Maintain a secure and organized record-keeping system that adheres to all regulatory and internal compliance standards, including HIPAA.
   • Update and manage provider profiles in credentialing databases, payer portals, and internal systems with accurate, real-time information.
   • Prepare detailed reports on enrollment and credentialing statuses for leadership, highlighting any delays, issues, or trends.
4. Compliance & Regulatory Adherence
   • Stay informed of local, state, and federal regulations that affect provider enrollment, credentialing, and FQHC compliance requirements.
   • Implement and reinforce policies, procedures, and best practices to align with NCQA, The Joint Commission, HRSA, and other relevant regulatory agencies.
   • Collaborate with the compliance department to address any non-compliance concerns, providing timely resolutions and updates.
5. Process Improvement & Leadership
   • Serve as the subject matter expert on credentialing and enrollment, offering guidance and training to junior staff and other team members.
   • Identify opportunities to streamline processes, reduce turnaround times, and enhance the accuracy and reliability of credentialing data.
   • Lead or participate in process-improvement initiatives, leveraging best practices and innovative solutions to optimize workflow efficiency.
   • Communicate regularly with clinical and administrative leadership to keep all stakeholders informed of enrollment and credentialing developments.
6. Provider Relations & Customer Service
   • Act as a liaison between providers, insurance payers, and internal departments to resolve credentialing-related inquiries and issues.
   • Deliver exceptional customer service to providers, ensuring they feel supported throughout the credentialing and enrollment process.
   • Develop and maintain strong relationships with payer representatives to facilitate quick resolutions of application or credentialing obstacles.

• Education:
  • Bachelor’s degree in healthcare administration, Business Administration, or a related field required. Master’s degree (e.g., MBA, MHA) is a plus.
• Experience:
  • Minimum of five (5) years of progressive experience in provider enrollment and credentialing, preferably within an FQHC or similar healthcare setting.
  • Demonstrated experience with Medicare, Medicaid, and commercial payer enrollment processes.
  • Prior leadership or supervisory experience is strongly preferred.
• Technical Skills & Knowledge:
  • In-depth knowledge of credentialing standards (e.g., NCQA, The Joint Commission) and compliance requirements applicable to FQHCs.
  • Proficiency in credentialing software, payer enrollment portals, including CAQH, PECOS, and NPPES.
  • Knowledge of Microsoft Office Suite (Word, Excel, PowerPoint).
  • Knowledge of EHR and practice management systems. EPIC is a plus.
  • Strong understanding of HIPAA requirements and information security best practices.
  • Familiarity with FQHC billing (Preferred but not required)
  • Familiarity with HRSA regulations and UDS reporting (Preferred but not required).
• Core Competencies:
  • Exceptional organizational skills with a high degree of accuracy and attention to detail.
  • Problem-solving and critical-thinking capabilities to handle complex enrollment challenges.
  • Excellent verbal and written communication skills for interacting with providers, internal teams, and external stakeholders.
  • Ability to mentor and guide junior staff; lead by example to foster a collaborative, high-performing team environment.
  • Capacity to handle multiple priorities, work under tight deadlines, and adapt to changing regulations.