Provider Operations Specialist

NourishedRx; Stamford (CT); On-site; USD 70,000 - 95,000; Full time

Job summary

NourishedRx in Stamford, CT is seeking a Provider Operations Specialist to support credentialing, payer enrollment, and claims coding for our provider network and Fee-for-Service operations.

You will collaborate with internal teams, payers, and vendors, maintain provider data, manage renewals, and help implement AI tools to automate workflows while ensuring HIPAA compliance.

Qualifications

• Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred. Equivalent relevant experience will be considered.
• 2-4 years of experience in healthcare operations, provider credentialing, payer enrollment, medical billing, or revenue cycle management.

Responsibilities

• Manage the provider credentialing and enrollment process with commercial health plans, Medicare, Medicaid, and other payer networks.
• Prepare, complete, and submit credentialing and enrollment applications for individual providers and organizational entities.
• Track application status, follow up with payers, and resolve outstanding requests or enrollment issues.
• Maintain provider credentialing files, including licenses, certifications, malpractice coverage, NPI information, and other required documentation.
• Monitor expiration dates and proactively manage recredentialing, license renewals, and other ongoing requirements.
• Coordinate with providers to obtain required information and documentation.
• Review, code, prepare, submit, and track Fee-for-Service healthcare claims.
• Apply appropriate CPT/HCPCS and ICD-10 diagnosis codes based on provider documentation and applicable payer billing guidelines.
• Ensure claims meet payer-specific billing requirements, including provider identifiers, place of service, modifiers, and other applicable billing information.
• Monitor claim status and work with internal teams and billing vendors to resolve rejections, denials, and payment discrepancies.
• Manage claims corrections, resubmissions, and appeals as appropriate.
• Monitor outstanding claims and support timely follow-up to ensure appropriate reimbursement.
• Maintain accurate billing records and documentation.
• Identify recurring billing issues and recommend opportunities to improve claims processes, coding accuracy, and reimbursement.
• Maintain accurate provider records across internal systems, payer portals, billing platforms, and other databases.
• Coordinate provider additions, changes, and terminations with payers and internal departments.
• Conduct periodic reviews to identify and correct discrepancies in provider data.
• Develop and maintain tracking tools, reports, and documentation to monitor credentialing, enrollment, billing, and provider data activities.
• Identify opportunities to streamline processes, improve accuracy, and increase operational efficiency.
• Help establish and maintain standard operating procedures as the organization grows.
• Work collaboratively with Finance, Clinical Operations, Technology, and other internal teams to support provider operations.
• Collaborate with external billing, credentialing, and other operational vendors as needed.
• Assist with special projects and other operational responsibilities as business needs evolve.
• Identify opportunities to leverage AI tools and automation to streamline provider operations, credentialing, payer enrollment, claims processing, and data maintenance.
• Help develop, implement, and maintain AI-enabled tools and processes that reduce manual work, improve accuracy, and increase operational efficiency.
• Explore and test emerging AI tools and technologies to identify practical applications for day-to-day operations.
• Collaborate with Technology and other internal teams to translate operational needs into automated solutions.
• Help build scalable processes that leverage AI to support the company's growth while maintaining appropriate data security, privacy, and compliance standards.

Skills

Organizational skills

Attention to detail

Problem solving

Communication skills

Education

Associate's or Bachelor's in Healthcare Administration

Experience in Healthcare Operations

Tools

Microsoft Office

Google Workspace

Job description

NourishedRx is transforming the way nutrition and healthcare intersect. Our mission is to provide personalized nutrition and food access solutions that enhance whole-person care and improve health outcomes. We believe in the power of healthy food and nutrition to improve health, and we strive to empower individuals and healthcare providers with the resources needed to support better health outcomes.

Position Summary

The Provider Operations Specialist is responsible for supporting the operational and administrative functions associated with NourishedRx's provider network and Fee-for-Service (FFS) business. This role oversees key activities related to provider credentialing, payer enrollment, claims coding and billing, and ongoing provider data maintenance.

Working across internal teams, healthcare providers, insurance companies, and external vendors, this individual helps ensure providers are appropriately credentialed, payer records are accurate and current, and services are billed accurately and timely.

This is a hands-on role in a fast-paced startup environment that requires strong organizational skills, attention to detail, problem-solving abilities, and the flexibility to take ownership of a variety of operational responsibilities. The ideal candidate is comfortable working independently, managing multiple priorities, and helping develop and improve processes as the company grows. An interest in leveraging AI and automation to improve operational efficiency is also important.

Key Responsibilities

Manage the provider credentialing and enrollment process with commercial health plans, Medicare, Medicaid, and other payer networks.

Prepare, complete, and submit credentialing and enrollment applications for individual providers and organizational entities.

Track application status, follow up with payers, and resolve outstanding requests or enrollment issues.

Maintain provider credentialing files, including licenses, certifications, malpractice coverage, NPI information, and other required documentation.

Monitor expiration dates and proactively manage recredentialing, license renewals, and other ongoing requirements.

Coordinate with providers to obtain required information and documentation.

2. Claims, Coding & Billing Operations

Review, code, prepare, submit, and track Fee-for-Service healthcare claims.

Apply appropriate CPT/HCPCS and ICD-10 diagnosis codes based on provider documentation and applicable payer billing guidelines.

Ensure claims meet payer-specific billing requirements, including provider identifiers, place of service, modifiers, and other applicable billing information.

Monitor claim status and work with internal teams and billing vendors to resolve rejections, denials, and payment discrepancies.

Manage claims corrections, resubmissions, and appeals as appropriate.

Monitor outstanding claims and support timely follow-up to ensure appropriate reimbursement.

Maintain accurate billing records and documentation.

Identify recurring billing issues and recommend opportunities to improve claims processes, coding accuracy, and reimbursement.

3. Provider Data & Network Maintenance

Maintain accurate provider records across internal systems, payer portals, billing platforms, and other databases.

Manage updates to provider demographic information, including addresses, practice locations, NPI numbers, tax identification information, licenses, and other enrollment details.

Ensure provider information is consistent across payer systems and internal platforms.

Track provider participation status, effective dates, termination dates, and payer network affiliations.

Coordinate provider additions, changes, and terminations with payers and internal departments.

Conduct periodic reviews to identify and correct discrepancies in provider data.

4. Operational Support & Process Improvement

Develop and maintain tracking tools, reports, and documentation to monitor credentialing, enrollment, billing, and provider data activities.

Identify opportunities to streamline processes, improve accuracy, and increase operational efficiency.

Help establish and maintain standard operating procedures as the organization grows.

Work collaboratively with Finance, Clinical Operations, Technology, and other internal teams to support provider operations.

Coordinate with external billing, credentialing, and other operational vendors as needed.

Assist with special projects and other operational responsibilities as business needs evolve.

5. AI & Automation

Identify opportunities to leverage AI tools and automation to streamline provider operations, credentialing, payer enrollment, claims processing, and data maintenance.

Help develop, implement, and maintain AI-enabled tools and processes that reduce manual work, improve accuracy, and increase operational efficiency.

Explore and test emerging AI tools and technologies to identify practical applications for day-to-day operations.

Collaborate with Technology and other internal teams to translate operational needs into automated solutions.

Help build scalable processes that leverage AI to support the company's growth while maintaining appropriate data security, privacy, and compliance standards.

Qualifications

Education

Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred. Equivalent relevant experience will be considered.

Experience

2-4 years of experience in healthcare operations, provider credentialing, payer enrollment, medical billing, or revenue cycle management.

Experience with professional medical billing and coding, including CPT, HCPCS, and ICD-10, preferred.

Familiarity with professional healthcare claims (CMS-1500) and commercial and/or government payer billing requirements.

Experience working with commercial health plans and/or government healthcare programs (Medicare and Medicaid) preferred.

Familiarity with provider credentialing, NPI registration, payer enrollment, and claims submission processes.

Experience billing nutrition or Medical Nutrition Therapy (MNT) services is preferred, but not required.

Experience working with payer portals, claims management systems, and provider databases preferred.

Willingness to obtain additional training in Registered Dietitian claims coding and payer-specific billing requirements.

Strong organizational skills and attention to detail, with the ability to manage multiple priorities and deadlines.

Working knowledge of healthcare provider credentialing, payer enrollment, and medical billing processes.

Strong problem-solving skills and the ability to independently research and resolve issues.

Excellent written and verbal communication skills, including the ability to work effectively with providers, payers, vendors, and internal teams.

Proficiency with Microsoft Office and/or Google Workspace.

Ability to work independently while collaborating effectively across departments.

Comfortable working in a fast-paced, evolving startup environment.

Self-starter with a willingness to take ownership, adapt to changing priorities, and help build processes as the organization grows.

Experience using AI tools or a demonstrated ability and interest in learning how to apply AI to automate processes, develop tools, and improve operational efficiency.

Additional Expectations

Demonstrate a commitment to the mission and values of NourishedRx.

Maintain confidentiality and handle provider and patient information in accordance with applicable HIPAA requirements and company policies.

Demonstrate flexibility and a willingness to support broader operational needs as the organization evolves.