Credentialing & Enrollment Specialist

The Credentialing and Enrollment Specialist helps us achieve our mission by ensuring our clinicians are properly credentialed and enrolled in payor networks to care for our patients. The responsibilities include timely submission of credentialing and re-credentialing of Ophelia’s providers, and the enrollment of Physicians, Nurse Practitioners, and Physician Assistants in managed care organizations and government payors such as Medicare and Medicaid, as well as many commercial plans. The Credentialing and Enrollment Specialist also maintains accurate provider records within various databases, including CAQH and payor portals.

The L&C Specialist works with a team of other specialists and collaborates closely with Clinical Operations, Billing, and Contracting teams to ensure our patient care functions smoothly. The role reports to the Licensing and Credentialing Team Lead.

• Review provider initial and reappointment credentialing applications, ensuring compliance with industry standards. 
• Conduct primary source verification and coordinate the credentialing committee review process
• Ensure new and renewed license, DEA, and CSR requests are submitted promptly 
• Follow up directly with providers to gather missing or incomplete information for enrollment submissions. 
• Submit enrollment packets to payors (MCOs, Medicare, Medicaid) in an accurate and timely manner.
• Monitor enrollment status and address any delays by following up with payors to expedite credentialing approvals. 
• Enter and maintain accurate provider enrollment data in internal and external databases, including CAQH and payor portals, by updating demographic information, practice locations, termination of providers, and other maintenance forms as required. 
• Act as a point of contact between providers, payors, and internal teams to resolve issues related to credentialing, enrollment, and reimbursement. 
• Other duties as assigned. 

• Associates degree or equivalent combination of education and experience
• 3-5 years of working experience in a credentialing and enrollment setting 
• Knowledge of multi-state/national provider credentialing and/or enrollment 
• Experience with PECOS/Medicare and/or state Medicaid enrollment platforms
• Knowledge of Google Workplace/Microsoft office or other task management suites
• National Association of Medical Staff Services (NAMSS), Certified Provider Credentialing Specialist (CPCS) certification a plus