Enrollment Provider & Credentialing Consultant

Job Summary

This is an independent contractor role.

Credentialing Verification

• Verify provider medical licenses, board certifications, DEA registrations, education, and malpractice insurance.
• Network Enrollment: Compile, complete, and submit detailed payer applications, track them to ensure completion, and resolve issues that prevent a provider from gaining "in-network" status with commercial insurance plans. Obtain and manage practice locations and provider rosters. Enroll individual clinicians and group practices in: Tricare, BCBS CareFirst, AETNA, CIGNA, United Healthcare, and other commercial payers as needed.

Database Maintenance

• Update and maintain accurate provider profiles in national databases and registries including CAQH and NPPES.

Tracking & Follow-up

• Monitor the status of pending applications with payers to ensure timely network approval and prevent credentialing gaps.
• Respond to payer requests for additional information.

Compliance Management

• Ensure compliance with payer and regulatory requirements.
• Track expiration dates for provider licenses, certificates, and insurances to ensure continuous compliance.
• Maintain enrollment records and approval dates.

Re-Credentialing & Revalidation Cycle

• Proactively update files and renew applications to maintain compliance with changing state, federal (CMS), and accrediting (NCQA/TJC) regulations.
• Manage the routine re-credentialing and revalidation processes mandated by insurers and regulatory bodies.

Issue Resolution

• Investigate and resolve enrollment delays, provider data errors, and credentialing-related billing rejections.

Contract Coordination

• Work with payer representatives during the contracting process.
• Ensure contracts are executed and effective dates are recorded.
• Track reimbursement schedules and network participation status.

Qualifications

• Education: High school diploma or GED required; bachelor’s degree in healthcare administration or a related field preferred.
• Experience: Minimum of 2–4 years of direct experience in medical credentialing and payer enrollment.
• Systems Proficiency: Hands-on experience using CAQH ProView, NPPES, and electronic medical record (EMR) software.
• Regulatory Knowledge: Deep understanding of NCQA and Joint Commission credentialing guidelines and compliance standards.
• Skill Set: Exceptional attention to detail, strong organizational skills, and excellent written and verbal communication abilities.

Preferred Qualifications

• Certification: Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) designation.
• Payer Network: Established relationships or familiarity with regional commercial health plan provider relations departments.