Sr. Provider Enrollment Specialist

The Provider Enrollment Sr. Specialist plays a critical role in ensuring healthcare providers are properly enrolled and credentialed with insurance payers, regulatory bodies, and internal systems to facilitate timely reimbursement and compliance. This position is responsible for overseeing the entire provider enrollment lifecycle—including initial credentialing, recredentialing, and demographic updates—while serving as a subject matter expert for internal teams. The Sr. Specialist will work collaboratively with payer representatives, provider relations, and revenue cycle teams to resolve complex enrollment issues and improve enrollment timelines, contributing to overall revenue integrity and operational efficiency. Provider Enrollment & Credentialing Responsibilities:

Manage and execute provider enrollment and recredentialing processes with commercial, Medicare, and Medicaid payers.

Ensure accurate and timely submission of enrollment applications and supporting documentation.

Monitor enrollment timelines, proactively following up with payers to avoid delays in reimbursement.

Maintain current knowledge of payer enrollment requirements, regulations, and industry standards.

Data Management & System Updates:

Accurately enter and maintain provider demographic and credentialing information in internal databases and payer portals.

Audit provider files and systems regularly to ensure accuracy and compliance.

Track and manage license renewals, CAQH attestation, NPI registrations, and other provider data elements required for successful enrollment.

Issue Resolution & Payer Communication:

Act as a liaison between payers, providers, and internal stakeholders to resolve enrollment issues, rejections, and lapses in network participation.

Escalate complex issues appropriately while maintaining thorough documentation and communication.

Collaborate with billing and denial management teams to resolve enrollment-related claim denials.

Compliance & Documentation:

Ensure compliance with all federal, state, and payer-specific guidelines related to provider enrollment.

Maintain detailed and organized records of all enrollment activities, correspondence, and approval letters.

Support audits and internal reviews by providing documentation and insight into provider status.

Collaboration & Cross-Functional Support:

Partner with Revenue Cycle, Provider Relations, and Credentialing teams to align enrollment efforts with organizational needs.

Provide subject matter expertise and mentorship to junior team members regarding enrollment best practices and processes.

Contribute to ongoing process improvements to enhance the accuracy, speed, and efficiency of provider onboarding and enrollment.

Required Qualifications:

Associate’s degree in Healthcare Administration, Business, or related field required (Bachelor’s preferred).

Minimum of 3-5 years of experience in provider enrollment, credentialing, or revenue cycle operations.

Strong understanding of payer enrollment processes for commercial, Medicare, and Medicaid plans.

Experience working with provider enrollment portals (e.g., PECOS, CAQH, Availity) and electronic credentialing systems.

Ability to analyze enrollment data and resolve complex payer or application issues effectively.

Proficiency in Microsoft Office Suite and experience with healthcare information systems (EHR, practice management systems).

Preferred Qualifications:

Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM).

Experience in a multi-specialty medical group or health system.