Credentialing & Enrollment Specialist

Jefferson Health Plans; Philadelphia (Philadelphia County); On-site; USD 52,000 - 78,000; Full time

Job summary

Jefferson Health Plans is seeking a Credentialing Specialist to manage credentialing and enrollment for JMG physicians with commercial and government payers. You will work with department staff to obtain and verify required documentation for a smooth enrollment process.

Responsibilities include preparing applications, tracking payer status, updating databases, and assisting with primary source verification. A strong foundation in managed care and NCQA standards is essential.

Qualifications

• HS diploma required; associates degree preferred.
• Minimum one year experience in a managed care setting.
• Understanding NCQA and managed care plans required.
• Prior credentialing/enrollment experience preferred.
• Experience with primary source verification preferred.
• Knowledge of credentialing/enrollment systems (Cactus) and CPCS preferred.

Responsibilities

• Prepare initial and recredentialing plan applications for JMG physicians and other contracted providers.
• Follow up and track provider applications submitted to payers and document status.
• Process changes and terminations from departments and practices in a timely manner.
• Investigate provider claim holds and request release once payer setup is confirmed.
• Assist the Delegated Credentialing team with Primary Source Verification for JP Committee submission.
• Update credentialing and enrollment databases, maintaining data integrity.

Skills

Payer contracting

CMS/PECOS enrollment

Multi-tasking

Attention to detail

Communication skills

Microsoft Office

Education

HS diploma

Associates degree or higher preferred

Tools

Cactus

Job description

Jefferson Health Plans is seeking a Credentialing Specialist to manage credentialing and enrollment for JMG physicians with commercial and government payers. You will work with department staff to obtain and verify required documentation for a smooth enrollment process.

Responsibilities include preparing applications, tracking payer status, updating databases, and assisting with primary source verification. A strong foundation in managed care and NCQA standards is essential.