Provider Enrollment and Credentialing Specialist

Job Description

Job Description

Position Summary:
The Credentialing Specialist is responsible for managing all aspects of the credentialing, recredentialing, and privileging processes for providers delivering patient care within the clinic and Ambulatory Surgery Center (ASC). This role ensures that all providers and the ASC maintain active, compliant credentials and privileges with health plans, hospitals, and regulatory entities. The Specialist will maintain accurate provider data across credentialing databases and systems, ensure timely renewal of all required documents, and support organizational compliance with payer and agency requirements.

Key Responsibilities

Credentialing & Compliance

• Maintain accurate and up-to-date credentialing data for all providers across internal databases and online systems.
• Complete and manage provider credentialing and recredentialing applications, ensuring timely submission and proactive follow-up.
• Ensure all provider documents—including state licenses, DEA certificates, malpractice coverage, and certifications—are current and compliant.
• Maintain thorough understanding of evolving health plan, regulatory, and agency requirements.
• Set up and maintain provider profiles in credentialing and payer enrollment systems.
• Track all license, certification, malpractice, and DEA expiration dates to ensure timely renewals.
• Ensure all practice and provider addresses are accurately reflected with health plans, agencies, and third-party entities.
• Process and track hospital appointment and reappointment applications for provider privileges.
• Audit health plan directories regularly to ensure accurate provider listings.
• Maintain and update fee schedule contacts with insurance payers.

Billing & Enrollment Support

• Apply working knowledge of medical billing and insurance claims rules as related to credentialing and payer enrollment.
• Review EOBs to identify denial trends related to credentialing or enrollment issues.
• Maintain and update CAQH profiles to ensure continuous payer compliance.

Other Duties

• Perform additional responsibilities and special projects as assigned.

Qualifications

Education:

• High school diploma or equivalent required.
• Associate degree preferred.

Experience:

• Minimum 2 years of credentialing or provider enrollment experience.
• 1–2 years of medical billing and insurance follow-up experience preferred.
• Experience with eClinicalWorks (eCW) preferred.

Skills & Competencies

• Strong knowledge of credentialing and provider enrollment processes.
• Excellent organizational skills with the ability to manage multiple priorities.
• Exceptional attention to detail and accuracy.
• Strong verbal and written communication skills, including professional correspondence.
• Ability to analyze data, research discrepancies, and solve problems effectively.
• Self-motivated with the ability to work independently with minimal supervision.
• Ability to build and maintain positive working relationships with providers, leadership, and external partners.
• Proficiency with Microsoft Office (Word, Excel, Access) and online credentialing systems.
• In-depth understanding of medical billing rules and insurance claims processes.
• Ability to review EOBs and identify credentialing-related denial patterns.
• Extensive experience with CAQH management and upkeep.

Ortho Sport and Spine Physicians is an Equal Opportunity Employer and does not discriminate in its employment practices on the basis of race, religion, sex, color, national origin, age, disability, citizenship, genetic information, veteran status, military service, or any other characteristic protected by federal law or Georgia law.