Credentialing Specialist

OrthoArizona; Arizona; On-site; USD 48,000 - 65,000; Full time

Job summary

OrthoArizona in Arizona is seeking a Credentialing Specialist to perform Medicare, AHCCCS and Commercial payor credentialing functions. This role reports to the Credentialing Supervisor and collaborates with Operations Leaders to onboard providers accurately and recredential timely.

You will manage credentialing applications, prepare weekly reports, ensure compliance with NCQA and payer requirements, and support audits.

Qualifications

• Strong working knowledge of Medicare and commercial payor credentialing standards, PECOS and AHCCCS.
• High proficiency with MS Office (Word, Excel, PowerPoint, Outlook).
• High School Diploma or equivalent.
• Experience in provider enrollment and credentialing for physicians and mid-level practitioners.
• Minimum of 3 years Medicare, AHCCCS, and commercial payor credentialing.
• Knowledge of credentialing software and NCQA credentialing requirements.

Responsibilities

• Process credentialing and recredentialing applications for medical providers and organization.
• Prepare weekly reports for division administrators and providers.
• Follow OrthoArizona, federal and state credentialing requirements.
• Assist with routine audits to ensure reimbursement aligns with current contracting and market rates.
• Prioritize work to ensure work is completed accurately within required deadlines.
• Submit required documents on schedule and follow-up as required. Promote a positive attitude, teamwork, and fun in the workplace.
• Ability to work independently and multi-task.
• Ability to communicate and work effectively with other employees, providers and health plans
• Maintain and ensure strict confidentiality of information and files.
• Working knowledge of NPI and CAQH; creating profiles, updating and maintenance of profiles.
• Knowledge of processing DME applications; CEDI and EFT enrollment regarding DME.
• Knowledge of creating payor rosters.
• Maintenance of providers' expirables including address updates with DEA. Monthly sanction, debarment and exclusion checks, including SAM, OIG and OFAC, state licensing.
• All other duties as assigned.

Skills

Medicare/Commercial credentialing

NCQA credentialing requirements

MS Office proficiency

Education

High School Diploma or equivalent

Tools

MS Office Suite

Job description

Our mission is to provide excellent, compassionate care to our patients, their families, and visitors. The responsibility of the Credentialing Specialist is to perform essential Medicare, AHCCCS and Commercial payor credentialing functions. This position reports to the Credentialing Supervisor and works closely with Operations Leaders to ensure providers are onboarded accurately and efficiently and re-credentialed timely.

Duties And Responsibilities

• Process credentialing and recredentialing applications for medical providers and organization.
• Prepare weekly reports for division administrators and providers.
• Follow OrthoArizona, federal and state credentialing requirements.
• Assist with routine audits to ensure reimbursement aligns with current contracting and market rates.
• Prioritize work to ensure work is completed accurately within required deadlines.
• Submit required documents on schedule and follow-up as required. Promote a positive attitude, teamwork, and fun in the workplace.
• Ability to work independently and multi-task.
• Ability to communicate and work effectively with other employees, providers and health plans
• Maintain and ensure strict confidentiality of information and files.
• Working knowledge of NPI and CAQH; creating profiles, updating and maintenance of profiles.
• Knowledge of processing DME applications; CEDI and EFT enrollment regarding DME.
• Knowledge of creating payor rosters.
• Maintenance of providers' expirables including address updates with DEA. Monthly sanction, debarment and exclusion checks, including SAM, OIG and OFAC, state licensing.
• All other duties as assigned.

Qualifications

• Strong working knowledge of Medicare and commercial payor credentialing standards, PECOS and AHCCCS
• High proficiency with MS Office (Word, Excel, PowerPoint, Outlook etc.).
• High School Diploma or equivalent
• Experience in provider enrollment and credentialing for physicians and mid-level practitioners
• Minimum of 3 years Medicare, AHCCCS, and commercial payor credentialing
• Knowledge of credentialing software and NCQA credentialing requirements