Credentialing Specialist

About the Role

Credifide is seeking a dedicated Credentialing Specialist to handle the comprehensive provider enrollment and primary source verification processes. This full-time position is based onsite in Mohali and operates during US shift timings from Monday to Friday. The Specialist will ensure accurate and timely completion of insurance panel applications, re-credentialing, and hospital privileging, collaborating closely with the Credentialing Team Lead on complex cases.

Position Responsibilities

• Manage preparation, submission, and tracking of initial credentialing and re-credentialing applications across specialties including Medicare, Medicaid, and Commercial payers.
• Perform primary source verifications of provider credentials such as education, licensure, certifications, and employment history according to NCQA and payer criteria.
• Maintain and update provider data profiles within CAQH, NPPES, and PECOS systems.
• Conduct thorough quality checks on credentialing applications before submission to avoid processing delays or denials.
• Follow up with payers to address application pendings, resolve discrepancies, and gather missing documents.
• Monitor expiration timelines for provider licenses, DEA registrations, and board certifications to ensure renewals are initiated promptly.
• Update centralized databases or spreadsheets reflecting the current status of provider files accurately.
• Escalate complex credentialing issues or multi-state enrollment challenges to supervisory staff when necessary.

Required Skills and Experience

• Minimum 3 to 4 years of experience in medical provider credentialing and enrollment.
• In-depth understanding of NCQA accreditation standards, CMS policies, and regional payer mandates.
• Proficient use of CAQH ProView, PECOS, and NPPES (NPI) portals along with advanced Excel capabilities for data management.
• Effective verbal and written communication skills for liaising with healthcare providers, office personnel, and insurance company representatives.
• Exceptional attention to detail to identify inaccuracies or omissions in documentation that might cause claim rejections.