Position Summary:

The Hospital and Payor Credentialing Specialist is responsible for managing and coordinating the credentialing and re-credentialing processes for physicians, healthcare providers, and facilities with both hospital systems and insurance payors. This position ensures compliance with regulatory requirements, maintains accurate provider information, and supports the hospital’s contracting and revenue cycle operations. The Credentialing Specialist will work closely with clinical staff, insurance companies, medical staff offices, and regulatory agencies to ensure timely and efficient provider credentialing and enrollment.

Key Responsibilities:1. Credentialing & Re-credentialing:Process initial credentialing and re-credentialing applications for physicians, advanced practice providers (APPs), allied health professionals, and other healthcare providers.Verify the accuracy of credentialing applications, including educational background, licensure, certifications, malpractice insurance, work history, and other required documents.Collect and maintain all necessary documents for hospital privileges, accreditation, and insurance provider networks.Submit and track credentialing applications to insurance payors (Medicare, Medicaid, commercial insurance) and hospital privileging committees.Work closely with the Medical Staff Office to ensure providers meet the hospital’s credentialing standards and procedures.Coordinate with clinical departments to ensure provider credentialing complies with specific specialty requirements. . Payor Enrollment & Contracting:Coordinate the enrollment of providers with health insurance payors (Medicare, Medicaid, PPOs, HMOs, etc.), ensuring accurate and complete applications.Assist in obtaining contracts and agreements with payors and maintain an up-to-date database of provider contracts and terms.Monitor and track the status of provider applications, follow up on outstanding or delayed enrollments, and resolve any issues with payor representatives.Maintain detailed records of provider participation status with various insurance carriers.Work with billing and coding teams to ensure that enrolled providers are listed accurately within payer systems to avoid claims denials. 3. Compliance and Regulatory Adherence:Ensure that all credentialing and enrollment processes comply with local, state, and federal regulatory requirements, including The Joint Commission (TJC), National Committee for Quality Assurance (NCQA), and other accrediting bodies.Assist with audits of credentialing files to ensure compliance with internal policies and external accreditation standards.Monitor and maintain updated knowledge of federal and state regulations regarding credentialing and payer enrollment.Ensure adherence to timelines and regulatory requirements for provider credentialing and payer enrollment.4. Communication & Coordination:Serve as the primary point of contact for providers, payors, and internal departments regarding credentialing and enrollment issues.Communicate with providers to gather necessary information and resolve any discrepancies or issues in the credentialing process.Liaise with insurance representatives to resolve any issues related to credentialing, contracting, or provider enrollment.Provide periodic status reports to the credentialing manager and relevant hospital departments regarding the status of provider credentialing and payer enrollment.5. Data Management & Reporting:Maintain accurate and up-to-date records of credentialing activities in the credentialing management system (CMS) or database.Generate reports as needed for audits, regulatory bodies, and internal management to ensure ongoing compliance with credentialing and enrollment standards.Track re-credentialing dates and initiate the re-credentialing process within the required timeframes.

Required Qualifications:Education:Associate’s degree in healthcare administration, business, or related field; Bachelor’s degree preferred.Experience:Minimum of 2-3 years of experience in hospital and/or payor credentialing or provider enrollment.Experience with hospital privileging processes, insurance provider enrollment, and regulatory compliance (NCQA, The Joint Commission, etc.) is preferred.Knowledge & Skills:Strong understanding of credentialing and payor enrollment processes, including knowledge of relevant regulations and payer requirements.Proficiency in credentialing software and Microsoft Office Suite (Excel, Word, Outlook).Excellent organizational skills with the ability to manage multiple projects and deadlines.Strong written and verbal communication skills.Ability to work independently and as part of a team in a fast-paced environment.Attention to detail and ability to handle confidential information with discretion.Certifications (preferred but not required):Certified Provider Credentialing Specialist (CPCS) from the National Association Medical Staff Services (NAMSS) or equivalent credentialing certification.

Physical Requirements:Ability to sit for extended periods and use a computer.Ability to communicate clearly via phone and email.Occasional lifting of materials up to 10 lbs.

Work Environment:This position operates in an office environment and/or from home office.  Must be available for in-person meetings as needed.You must be located in Augusta, GA, Ocala, FL, or Sarasota, FL (or be willing to relocate).

 Compensation:This position offers an hourly rate between $15 and $20 per hour.

 Schedule:This role involves 15-20 hours of work per week, primarily during weekdays, within standard business hours.