Provider Credentialing & Payer Enrollment Specialist

Provider Credentialing & Payer Enrollment Specialist (Full Time)

Join to apply for the Provider Credentialing & Payer Enrollment Specialist (Full Time) role at Kingman Regional Medical Center.

All KHI employees are expected to perform their respective tasks and duties in such a way that supports KHI’s vision of providing the region’s best clinical care and patient service through an environment that fosters respect for others and pride in performance.

The primary function of the Provider Credentialing and Payer Enrollment Specialist is to collect and verify physician and authorized practitioner credentialing data for use in the Payer Enrollment and Medical Staff Services credentialing and privileging functions. This individual facilitates practitioners through the organization’s payer enrollment process, enrolls providers and hospital facilities with contracted insurance payers for billing purposes, requests, collects, verifies, and coordinates application materials, reviews returned material for accuracy, regularly communicates with key stakeholders, and reports applicant status during the enrollment process.

The Specialist ensures all required documentation is obtained and maintains effective relationships with providers, medical staff, insurers, business office/billing staff, and others to promote timely completion of related processes. The Specialist maintains a working knowledge of TJC, DNV, and NCQA standards related to medical staff and payer credentialing processes.

• Support the full scale of data collection and verification processes for medical staff services and payer enrollment.
• Compile, evaluate, and present provider-specific information for use by Medical Staff Services and in the Payer Enrollment process.
• Conduct primary source verification of initial and reappointment applications in accordance with Accreditation, Regulatory, and Medical Staff Bylaws; obtain provider sanctions, complaints and adverse data.
• Communicate with providers via e‑mail, phone, written, and face‑to‑face to gather signatures and information necessary to complete new provider enrollment and updates.
• Coordinate the sharing of payer enrollment data needed for enrollment, contracting, and related purposes with providers, Medical Staff Services, managers, insurers, and other stakeholders.
• Collect educational certifications, DEA number, state license number, board certification, CV, malpractice insurance, and state insurance data.
• Maintain data input and data integrity for the MD Staff electronic credentialing data management program.
• Process requests related to physician maintenance in hospital and clinic HIS systems and communicate additions or changes to appropriate parties.
• Oversee provider enrollment software upgrades and ongoing changes.
• Keep current with insurance plan requirements, implement changes and maintain plan compliance.
• Review State Report for corrections necessary to provider maintenance.
• Maintain provider payer enrollment files and an accurate physician-provider grid for all participating plans.
• Maintain an accurate provider membership directory for each network, ensuring all employed physicians are properly loaded in the vendor listing.
• Update facility payer enrollment with all payers and coordinate with Billing and Collections teams to prevent payer enrollment denials.
• Complete new provider packets within 10 days of employment and notify all plans via application for enrollment to ensure timely affiliation.
• Update provider attestation for CAQH every 120 days as permitted.
• Follow up within established time frames with insurance carriers or networks regarding submitted documentation.
• Provide immediate updates to Business Office staff of finalized credentials.
• Monitor and advise physicians on upcoming license expirations.
• Notify plans when physicians are terminated or leave employment within established timeframe.
• Monitor department email for incoming credentialing requests, data entry updates, and changes; respond and communicate to providers and staff timely.
• Maintain provider rosters quarterly via email and online systems.
• Coordinate with third‑party vendors to…