Provider Enrollment & Credentialing Coordinator

Job Summary:

The Provider Enrollment & Credentialing Coordinator is responsible for all aspects of provider enrollment, credentialing, recredentialing, and privileging processes for employed and contracted practitioners. This includes maintaining accurate provider data in credentialing databases, ensuring timely submission and renewal of required documentation and supporting compliance standards. The Coordinator will work closely with providers, payers, and internal departments to ensure practitioners are appropriately credentialed and enrolled to support timely patient access and reimbursement.

Responsibilities:

• Coordinate initial credentialing and recredentialing for physicians, physician assistants, and advanced practice providers across Medicare, Medicaid, commercial insurers, and delegated payers.

• Obtain and maintain NPI provider numbers utilizing the PECOS, Medicaid, Availity and NPPES websites.

• Prepare Credentialing files for FOI Credentialing Committee. This would include completing all required primary source verifications.

• Track and maintain provider insurance participation status and effective dates in Athena.

• Maintain timely and accurate data entry in credentialing databases and payer portals; update provider rosters and profiles as needed.

• Process facility privilege applications and reappointments of privileges.

• Monitor and manage expirable documents (licenses, DEA, board certifications, malpractice insurance), alerting providers and escalating unresolved expirations to the Manager.

• Submit and update provider information in the CAQH ProView system as required by participating health plans.

• Ensure compliance with NCQA, URAC, CMS, and payer requirements for provider credentialing and enrollment.

• Assist with issue resolution and communication with payers regarding credentialing/enrollment status and delays.

• Upload and track CME documentation in relevant databases (e.g., CE Broker).

• Communicate credentialing or enrollment issues and application delays to the Manager in a timely manner.

• Participate in internal audits, special projects, and process improvements as directed.

• Perform other duties as assigned by department leadership.

Education And Experience:

• Healthcare administration, business, or a related field preferred.

• Minimum 2 years of experience in provider credentialing or enrollment, preferably in a healthcare, medical group, or managed care environment.

• Working knowledge of:

• Credentialing standards (NCQA, URAC, CMS)

• Credentialing software and payer enrollment systems

• Proficiency in Microsoft Excel and Office Suite; comfort with electronic databases and file management systems.

• Strong attention to detail, organization, and ability to manage multiple tasks and deadlines.

• Effective verbal and written communication skills, especially in provider-facing interactions.

• Ability to handle sensitive data with a high level of confidentiality and accuracy.

Prefferred Qualifications & Skills 

• Prior experience with delegated credentialing or payer audit support

• Experience using Athenahealth and VerityStream platforms

• Basic understanding of medical terminology and healthcare regulations

• CPCS (Certified Provider Credentialing Specialist) certification preferred but not required

Orthopaedic Solutions Management is a Drug Free Workplace

We are committed to maintaining a safe, healthy, and productive work environment. As part of this commitment, we operate as a drug-free workplace. All candidates will be required to undergo pre-employment drug screening and/or be subject to random drug testing in accordance with applicable laws and company policy.