Credentialing & Payer Enrollment Specialist

Description:

Who We Are

nimble solutions has over 20 years of specialized, surgical-focused revenue cycle management experience that spans across the ambulatory surgical center (“ASC”) industry and other affiliated services adjacent to the ASC space, such as anesthesia billing services, professional billing services, transcription services, and many others. We provide services in nearly every U.S. state, and our team of experts works around the globe, having managed over $10 billion in net collections as we continue to build and innovate a world-class organization with people like you.

Together, we embrace challenges, fuel innovation, and strive to exceed expectations. Healthcare means a lot more to us. We care about creating an environment where our coworkers’, clients’, and communities’ social, financial, and physical health is at the forefront of everything we do. From our cutting-edge technology to our endless opportunities for growth, we are a community of people who care deeply about our employees and their futures. We look forward to your thirst for learning, developing, and growing with our team.

The Credentialing & Payer Enrollment Specialist is responsible for managing provider credentialing, payer enrollment, electronic data interchange (EDI) enrollment, and payer portal administration for healthcare providers and organizations.

This position requires hands-on experience working with commercial and government payers, CAQH, PECOS, payer portals, clearinghouses, and provider enrollment systems. The specialist will manage the enrollment process from initial application through approval and ensure that individual providers are properly credentialed and linked to the appropriate group, Tax ID/TIN, and billing entity.

The ideal candidate is highly organized, detail-oriented, and capable of independently researching, submitting, tracking, and resolving enrollment and credentialing issues.

Responsibilities

  

Provider Credentialing & Enrollment

• Manage end-to-end provider de-credentialing, and payer enrollment processes
• Complete and submit enrollment applications for Medicare, and commercial insurance payers
• Enroll and/or link individual providers to existing groups, Tax IDs/TINs, NPIs, and billing entities
• Process new provider enrollments, group affiliations, demographic changes, reassignments, revalidations, and terminations as applicable
• Verify provider information, including NPI, licensure, DEA registration, malpractice coverage, board certification, practice locations, and other required credentials
• Monitor payer applications through completion and perform timely follow-up on outstanding enrollment requests

CAQH & PECOS

• Create, maintain, and update provider CAQH profiles
• Complete CAQH attestations and ensure provider documents and demographic information remain current
• Manage payer authorization within CAQH as necessary
• Utilize PECOS to complete Medicare-related provider and organization enrollment activities
• Process Medicare enrollments, reassignments, revalidations, changes of information, and other applicable transactions through PECOS
• Track Medicare applications and respond to requests for additional information

EDI, ERA & EFT Enrollment

• Complete and monitor EDI, ERA, and EFT enrollments with applicable insurance payers
• Understand payer-specific electronic enrollment requirements and determine when separate enrollment is required
• Coordinate electronic enrollment between providers, payers, billing entities, and clearinghouses
• Troubleshoot enrollment issues that may prevent successful electronic claim submissions or remittance processing.
• Verify enrollment completion and effective dates before communicating billing readiness

Clearinghouse Experience

• Work with TriZetto or comparable healthcare clearinghouse platforms to support payer and electronic enrollment functions
• Assist with EDI and ERA enrollment and troubleshooting when necessary
• Research enrollment or connectivity issues between providers, payers, and clearinghouses
• Coordinate with billing and revenue cycle teams to resolve enrollment-related claim submission issues

Payer Portal Administration

• Create and maintain provider and organizational accounts within insurance payer portals
• Link providers, groups, NPIs, and Tax IDs/TINs to appropriate payer portal accounts.
• Manage portal access, authorization, and administrator permissions when applicable.
• Utilize payer portals to: 
  • Submit enrollment information
  • Monitor application status
  • Maintain provider demographics
  • Complete roster updates
  • Manage ERA/EFT enrollment
  • Verify network participation
  • Research provider enrollment status

Out-of-Network Provider Support

• Support credentialing and payer-related processes for out-of-network providers when applicable
• Research payer requirements and determine whether credentialing, registration, enrollment, or other provider information is required
• Maintain accurate documentation regarding network and enrollment status

Tracking, Documentation & Follow-Up

• Maintain detailed records of all credentialing and enrollment activity
• Track application submission dates, payer reference numbers, effective dates, follow-up dates, outstanding requirements, and final approvals
• Proactively follow up with payers to resolve delayed or incomplete applications
• Monitor provider credential expirations and initiate renewals or recredentialing before expiration
• Maintain accurate credentialing and enrollment status reports for management and operational teams
• Manage multiple providers, payer applications, and client accounts simultaneously while meeting established deadlines

Revenue Cycle Collaboration

• Work closely with billing, AR, contracting, credentialing, and other revenue cycle teams to ensure providers are ready for claim submission
• Confirm provider enrollment and effective dates before communicating billing readiness
• Research enrollment-related claim issues and assist in determining whether a denial or rejection is related to credentialing or payer enrollment
• Escalate payer enrollment issues that may negatively affect reimbursement or timely claim submission

Requirements:

  

• Minimum 2 years of healthcare credentialing, provider enrollment, or payer enrollment experience preferred
• Hands-on experience with CAQH
• Experience utilizing PECOS for Medicare provider enrollment
• Knowledge of Medicare, and commercial payer enrollment processes
• Experience working directly with insurance payer portals.
• Experience linking or enrolling individual providers under group NPIs and Tax IDs/TINs
• Understanding of EDI, ERA, and EFT enrollment processes
• Experience with TriZetto or another healthcare clearinghouse preferred
• Knowledge of provider credentialing and recredentialing requirements
• Ability to independently research payer requirements and troubleshoot enrollment problems
• Strong documentation and follow-up skills
• Ability to manage multiple provider applications and deadlines simultaneously
• Strong written and verbal communication skills
• Proficiency with Microsoft Office and healthcare enrollment/credentialing systems

Preferred Qualifications

• Experience working within a Revenue Cycle Management (RCM) organization
• Experience supporting multiple practices, providers, or client accounts
• Experience with Medicare enrollment
• Experience managing payer portal account creation and access
• Experience with out-of-network provider credentialing/enrollment processes
• Familiarity with payer contracting and its relationship to credentialing and provider enrollment
• CPCS (Certified Provider Credentialing Specialist) or CPMSM certification is a plus but not required

Ideal Candidate

The ideal candidate should be able to independently explain and perform the following: 

• ERA and EDI enrollment
• Payer-specific EDI requirements
• TriZetto or another clearinghouse
• Commercial and government payer portals
• Creating and maintaining payer portal accounts
• CAQH profile management and attestation
• PECOS and Medicare enrollment
• Out-of-network provider credentialing/enrollment
• Linking individual providers to a group NPI and Tax ID/TIN
• Tracking enrollment from submission through effective date
• Troubleshooting enrollment issues
• Determining when a provider is fully enrolled and ready for billing

Work Environment

• Fast-paced, deadline-driven RCM vendor environment
• Remote work setting with cross-functional collaboration across clients, operations, and payer teams
• Must maintain confidentiality of provider and client data at all times