- Own the full lifecycle of credentialing for physicians and advanced practice providers, including initial onboarding, primary source verification, re-credentialing, and ongoing monitoring.
- Verify education, training, licenses, board certifications, malpractice insurance, and work history with complete accuracy.
- Ensure all credentialing files meet NCQA, TJC, CMS, and payer-specific requirements.
- Prepare, submit, and track enrollment applications with commercial payers including BCBS, UHC, Aetna, and Cigna, as well as Medicare and Medicaid.
- Manage CAQH ProView including quarterly attestations and document maintenance.
- Process Medicare enrollments and updates through PECOS.
- Verify that providers are correctly linked to group tax IDs to prevent out-of-network billing issues.
- Track effective dates and panel statuses and communicate updates to internal stakeholders.
- Create structure in areas that currently have few or inconsistent processes.
- Organize credentialing inputs from multiple sources and turn them into clear workflows, trackers, and checklists.
- Identify bottlenecks, design solutions, and implement improvements that enhance accuracy, speed, and consistency.
- Document processes and maintain updated SOPs that support ongoing team alignment and scale.
- Work closely with internal teams to keep credentialing and enrollment workflows moving.
- Support account managers, operations, and revenue cycle teams by providing accurate status updates and resolving credentialing-related blockers.
- Partner with billing and AR teams to investigate and resolve claim denials caused by credentialing or enrollment issues.
- Maintain accurate provider data across CAQH, PECOS, payer portals, and internal systems.
- Own a master tracker that includes effective dates, expirables, re-credentialing deadlines, panel statuses, and outstanding items.
- Keep all credentialing records continuously audit-ready with complete and up-to-date documentation.
- Monitor expiring state licenses, DEA registrations, malpractice insurance, and board certifications.
- Communicate proactively with providers to ensure renewals are completed well before expiration dates.
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