Position Summary

The Senior Credentialing Specialist / Credentialing Lead is responsible for overseeing and managing the full provider credentialing and recredentialing lifecycle across a multi-provider, multi-location healthcare organization. This position manages credentialing with commercial and government payers, hospital and facility privileges, provider enrollment, recredentialing, licensing, and ongoing provider maintenance.

The ideal candidate has extensive hands-on credentialing experience and is highly organized, proactive, and comfortable independently managing a large volume of providers, payers, facilities, deadlines, and outstanding applications. This individual will serve as the internal credentialing subject matter expert, lead the credentialing function, maintain accurate tracking and reporting, and ensure providers remain appropriately credentialed and enrolled without unnecessary delays or disruptions.

Key Responsibilities

· Manage the full credentialing and recredentialing process for physicians, advanced practice providers, and other applicable clinicians.

· Manage credentialing and enrollment across multiple commercial payers, Medicare, Medicaid, and other government programs.

· Complete and maintain provider enrollment applications, revalidations, demographic updates, reassignment requests, and other payer-required submissions.

· Manage hospital and facility privileging, including initial applications, reappointments, renewals, and ongoing maintenance of privileges.

· Maintain provider information and documentation, including CAQH profiles, NPI/NPPES, PECOS, licenses, DEA registrations, malpractice coverage, board certifications, CVs, and other credentialing documents.

· Proactively monitor expiration dates and renewal requirements to prevent lapses in licenses, certifications, privileges, enrollment, or other required credentials.

· Maintain a comprehensive credentialing tracker/dashboard showing the status of each provider by payer, facility, application, effective date, outstanding item, and next action.

· Follow up consistently with payers, hospitals, providers, and other organizations to move applications through the credentialing process and resolve delays.

· Verify payer effective dates and provider participation status before considering credentialing complete.

· Research and resolve credentialing discrepancies, enrollment issues, application delays, closed panels, payer errors, and other barriers.

· Communicate directly with payer credentialing departments, Medicare/Medicaid representatives, hospital medical staff offices, providers, practice leadership, and internal departments.

· Coordinate credentialing for new provider onboarding to ensure applications are initiated as early as possible and providers are ready to practice and bill within expected timelines.

· Support credentialing associated with new practices, acquisitions, new locations, tax IDs/TINs, and organizational growth.

· Maintain accurate provider rosters and submit payer roster updates, additions, terminations, demographic changes, and location changes as required.

· Manage provider terminations and ensure appropriate notifications and updates are completed with payers and facilities.

· Maintain organized and audit-ready credentialing files and documentation.

· Track credentialing turnaround times, outstanding applications, upcoming expirations, and other key performance indicators.

· Provide regular credentialing status reports to leadership and promptly escalate delays or risks that may impact provider scheduling, billing, or revenue.

· Develop and maintain standardized credentialing workflows, policies, procedures, checklists, and tracking tools.

· Identify opportunities to improve credentialing processes, reduce delays, and increase accountability.

· Serve as the primary internal resource for questions regarding credentialing, payer enrollment, and hospital privileges.

· Provide guidance and oversight to credentialing staff and assist with workload prioritization, training, and quality review.

· Work closely with Operations, Revenue Cycle, Compliance, HR, Legal, providers, and practice leadership to ensure credentialing requirements are met.

· Maintain confidentiality of provider and organizational information and ensure compliance with applicable regulatory and accreditation requirements.

Required Qualifications

· Minimum 5 years of hands-on provider credentialing and payer enrollment experience, preferably within a multi-provider, multi-location healthcare organization.

· Extensive experience managing credentialing for a high volume of providers and multiple payers simultaneously.

· Strong knowledge of the complete provider credentialing, recredentialing, and payer enrollment lifecycle.

· Demonstrated experience with commercial payer, Medicare, and Medicaid enrollment and maintenance.

· Demonstrated experience managing hospital/facility privileges, initial appointments, and reappointments.

· Strong working knowledge of CAQH, NPPES/NPI, PECOS, payer portals, provider rosters, and credentialing databases/tracking systems.

· Experience monitoring and maintaining provider licenses, DEA registrations, malpractice insurance, board certifications, and other credentialing requirements.

· Experience with provider onboarding, payer effective dates, demographic changes, location additions, terminations, and revalidations.

· Ability to independently research and resolve complex credentialing and enrollment issues.

· Strong understanding of how credentialing delays and enrollment errors can impact billing, reimbursement, provider scheduling, and revenue cycle operations.

· Advanced organizational and tracking skills with exceptional attention to detail.

· Ability to manage multiple competing priorities, deadlines, and follow-up requirements with minimal supervision.

· Strong written and verbal communication skills and the ability to communicate professionally with providers, payers, hospital representatives, and leadership.

· Proficiency with Microsoft Office, particularly Excel, and experience using credentialing software and payer portals.

Preferred Qualifications

· CPCS (Certified Provider Credentialing Specialist) or similar credentialing certification preferred.

· Experience leading or supervising a credentialing team or department.

· Experience developing credentialing workflows, policies, procedures, and performance metrics.

· Experience supporting credentialing during practice acquisitions, organizational growth, new locations, and new TINs/entities.

· Experience working within a multi-specialty physician group or healthcare management organization.

Key Competencies

· Highly organized and detail-oriented.

· Proactive with follow-up and deadline management.

· Able to independently own projects from initiation through completion.

· Comfortable holding others accountable for outstanding documentation and requirements.

· Skilled at identifying credentialing risks before they impact operations or revenue.

· Able to prioritize urgent provider and payer issues appropriately.

· Strong at problem-solving and navigating complex payer and hospital processes.

· Capable of leading the credentialing function while remaining actively involved in day-to-day credentialing work.

· Effective at communicating credentialing status, barriers, and risks to leadership in a clear and concise manner.