Insurance Credentialing Specialist

AP Professionals has partnered with a local nonprofit health organization in search of an Insurance Credentialing Specialist. This role ensures all providers maintain active status by completing initial and ongoing credentialing processes required by hospitals, commercial insurers, Medicare, and Medicaid. This role also involves keeping provider information current in credentialing databases and online systems, as well as managing timely renewals of licenses and certifications.

• Maintain and update individual provider files with current information required for government and commercial payer credentialing applications.
• Manage the internal provider grid to ensure data accuracy and maintain login credentials.
• Maintain up-to-date provider profiles in CAQH, PECOS, NPPES, and CMS databases.
• Ensure the confidentiality of all provider information.
• Regularly update CAQH files in accordance with CMS schedules.
• Apply for and renew providers' licenses, including Professional, DEA, and Controlled Substance licenses.
• Complete revalidation processes for government payers.
• Submit applications to enroll and re-enroll providers with commercial payers, Medicare, and Medicaid.
• Coordinate initial credentialing and re-credentialing for providers with affiliated hospitals.
• Ensure provider practice addresses are current with payers, agencies, and other entities.
• Conduct regular audits of health plan directories to verify provider information accuracy.
• Review payer communications and share relevant updates with internal stakeholders.
• Collaborate with the Director of Revenue Cycle and billing staff to resolve credentialing-related denials or authorization issues.
• Participate in meetings with insurance representatives as needed.
• Support the development of continuous improvement strategies for the Revenue Cycle department.
• Adhere to all departmental and organizational policies and procedures.
• Perform additional duties as assigned by the Director of Revenue Cycle.

• Associate’s or Bachelor’s degree.
• Certified Provider Credentialing Specialist (CPCS).

• At least 3 years of relevant credentialing experience.

• Solid understanding of provider credentialing and its impact on the revenue cycle
• Strong organizational and prioritization skills
• Excellent written and verbal communication abilities
• Detail-oriented with strong analytical and research skills
• Self-motivated and able to work independently
• Proven ability to build effective relationships with internal and external stakeholders
• Professional demeanor and conduct
• Proficient in Microsoft Office, Adobe PDF, internet use, and standard office equipment
• Capable of multitasking and adapting to new challenges regularly