Payer Enrollment Specialist

METRO COMMUNITY HEALTH CENTER•Pittsburgh, PA

2d•Onsite

About The Position

We are seeking a highly organized and detail-oriented FQHC Insurance Credentialing Specialist to oversee the credentialing and re-credentialing processes for a team of 20+ medical, mental health, and dental providers. This role is responsible for ensuring that all providers meet compliance requirements with federal, state, and commercial insurance regulations, as well as accrediting and licensing bodies. The ideal candidate will have extensive experience in credentialing within a Healthcare or preferably Federally Qualified Health Center (FQHC) setting and the ability to manage the entire credentialing life cycle efficiently. ESSENTIAL FUNCTIONS: Manage and oversee the insurance credentialing and re-credentialing process for all providers, including medical, mental health, and dental professionals. Maintain up-to-date and accurate insurance credentialing files in accordance with organizational policies and regulatory requirements. Ensure timely submission and follow-up on insurance credentialing and payer enrollment applications with Medicare, Medicaid, and commercial insurance providers. Monitor provider licenses, DEA registrations, and certifications to ensure compliance with expiration dates and renewal requirements. Collaborate with internal departments, including Human Resources, Billing, and Compliance, to streamline provider onboarding and credentialing processes. Develop and implement policies and procedures to enhance the efficiency and accuracy of the credentialing process. Serve as the primary liaison between the organization and credentialing bodies, insurance networks, and regulatory agencies. Conduct periodic audits of provider files and credentialing databases to ensure compliance with internal and external standards. Respond to requests for information from insurance companies, licensing agencies, and other credentialing entities. Track and report credentialing metrics to leadership, identifying potential delays and providing solutions for process improvements. Stay updated on changes in credentialing regulations and payer requirements, ensuring continuous compliance. QualificationsPOSITION REQUIREMENTS: Education/Experience Degree or certification in healthcare administration, business administration, or a related field preferred. Equivalent work experience may be considered. Minimum of 3-5 years of provider credentialing experience, preferably in an healthcare setting. Certified Insurance Credentialing Specialist (CICS) or Certified Professional Medical Services Management (CPMSM) preferred but not required. In-depth understanding of credentialing, provider enrollment, and regulatory requirements for Healthcare/FQHCs. Skills/Abilities Strong attention to detail and organizational skills. Ability to manage multiple priorities and meet deadlines. Excellent written and verbal communication skills. Proficiency in credentialing software, electronic health records (EHR), and Microsoft Office Suite. Ability to work independently and as part of a team in a fast-paced environment. Physical Requirements While performing the duties of this job, the employee is regularly required to sit; use hands to manipulate objects, tools or controls; reach with hands and arms; and talk and hear. The employee must be able to occasional lift and/or move up to 15 pounds. Specific vision abilities required by this job include close vision, distance vision, peripheral vision, depth perception and the ability to adjust focus. Noise level in the work environment is usually quiet.

Requirements

Degree or certification in healthcare administration, business administration, or a related field preferred. Equivalent work experience may be considered.
Minimum of 3-5 years of provider credentialing experience, preferably in an healthcare setting.
In-depth understanding of credentialing, provider enrollment, and regulatory requirements for Healthcare/FQHCs.
Strong attention to detail and organizational skills.
Ability to manage multiple priorities and meet deadlines.
Excellent written and verbal communication skills.
Proficiency in credentialing software, electronic health records (EHR), and Microsoft Office Suite.
Ability to work independently and as part of a team in a fast-paced environment.

Nice To Haves

Certified Insurance Credentialing Specialist (CICS) or Certified Professional Medical Services Management (CPMSM) preferred but not required.

Responsibilities

Manage and oversee the insurance credentialing and re-credentialing process for all providers, including medical, mental health, and dental professionals.
Maintain up-to-date and accurate insurance credentialing files in accordance with organizational policies and regulatory requirements.
Ensure timely submission and follow-up on insurance credentialing and payer enrollment applications with Medicare, Medicaid, and commercial insurance providers.
Monitor provider licenses, DEA registrations, and certifications to ensure compliance with expiration dates and renewal requirements.
Collaborate with internal departments, including Human Resources, Billing, and Compliance, to streamline provider onboarding and credentialing processes.
Develop and implement policies and procedures to enhance the efficiency and accuracy of the credentialing process.
Serve as the primary liaison between the organization and credentialing bodies, insurance networks, and regulatory agencies.
Conduct periodic audits of provider files and credentialing databases to ensure compliance with internal and external standards.
Respond to requests for information from insurance companies, licensing agencies, and other credentialing entities.
Track and report credentialing metrics to leadership, identifying potential delays and providing solutions for process improvements.
Stay updated on changes in credentialing regulations and payer requirements, ensuring continuous compliance.