Credentialing / Enrollment Specialist

Job Description

Job Description

Description :

The Credentialing and Enrollment Specialist is responsible for managing all aspects of provider credentialing and payer

enrollment in accordance with NCQA standards, regulatory requirements, and organizational policies. This position

ensures timely and accurate credentialing, recredentialing, and maintenance of provider files, including monitoring and

updating all expirables such as licenses, certifications, and malpractice coverage. The specialist coordinates hospital

privilege applications and renewals, while also facilitating multi-state provider enrollment with commercial and government

payers. This role requires a high level of attention to detail, organizational skills, and the ability to manage multiple

priorities to support compliance and ensure uninterrupted provider participation in payer networks and hospital systems.

Duties and Responsibilities

• Process and manage initial and recredentialing applications in compliance with NCQA standards, payer requirements, and organizational policies.
• Maintain accurate and up-to-date provider credentialing files, ensuring timely collection and verification of licenses, certifications, malpractice coverage, DEA, and other required documents.
• Monitor and track expirables, proactively notifying providers and leadership of upcoming renewals to prevent lapses in compliance.
• Coordinate hospital privilege applications, renewals, and ongoing maintenance for assigned providers.
• Facilitate provider enrollment and re-enrollment with commercial and government payers across multiple states.
• Serve as liaison between providers, payers, and internal departments to resolve credentialing and enrollment issues.
• Ensure timely submission of applications to avoid delays in payer participation and reimbursement.
• Conduct regular audits of provider files to verify compliance with accreditation and regulatory standards.
• Maintain credentialing databases and tracking systems with accurate, real-time information.
• Prepare reports and updates for leadership regarding provider credentialing and enrollment status.
• Support organizational compliance by staying current on changes in credentialing regulations, payer requirements, and NCQA standards.
• Understands, complies with, and enforces all NSPC policies, procedures, codes of conduct, and OSHA and HIPAA privacy rules.
• Adhere to and uphold all applicable federal and state compliance regulations as well as NSPC’s Code of Conduct and Employee Handbook, compliance policies and procedures, and applicable healthcare fraud, waste and abuse laws.
• The Code of Conduct
• Annual completion of compliance training
• Adherence to the overall compliance program
• All other duties as assigned.

Requirements :

Qualifications and Skills

Working Conditions

Physical Requirements