Credentialing and Enrollment Specialist

Position Overview A successful Credentialing and Enrollment Specialist (CES) must be passionate about healthcare and want to make a difference in the lives of others while acting as a mission-driven catalyst to help Livingston Community Health (LCH) deliver the best quality of care and excellent service to our patients and their families.

The Credentialing and Enrollment Specialist is responsible for coordinating and managing all aspects of provider credentialing, re-credentialing, privileging, and payor enrollment at the Federally Qualified Health Center (FQHC).

Also, responsible for facility, site, and service-line licensing.

Essential Functions, Duties, andResponsibilities Ensures the organization maintains compliance with HRSA, FTCA, CMS, NCQA, and other applicable regulatory and accrediting bodies, facilitating timely provider onboarding and payor enrollment.

Responsible for facility, site, and service-line licensing, ensuring timely renewals, accurate postings, and alignment with payer/site enrollments.

Credentialing & Privileging Manage the full credentialing lifecycle for licensed providers and other credentialed staff, including initial credentialing, primary source verification, and recredentialing every two years.Coordinate the privileging process, ensuring all privilege requests are complete, appropriately reviewed, and approved by the Board of Directors.Maintain accurate and complete provider files, credentialing database, and credentialing software systems.Track and verify license, DEA, BLS, malpractice insurance, board certifications, NPDB, and other required documents to ensure ongoing compliance.Coordinate and track annual peer review results and ensure the Chief Medical Officer (CMO) reviews and incorporates them into the recredentialing and reprivileging process.Prepare reports for the Quality Committee, Medical Executive Committee, and Board of Directors regarding credentialing and privileging status.

Payor Enrollment Manage enrollment and re-enrollment with all contracted health plans (Medicaid, Medicare, and commercial insurers).Prepare, submit, and track all enrollment applications, including provider adds, terminations, demographic updates, and reassignment of benefits.Maintain accurate payor rosters and CAQH profiles for all providers.Monitor effective dates and ensure billing and reimbursement are not delayed.Collaborate with the billing and revenue cycle teams to resolve enrollment-related claim denials.

Facility Licensing Maintain a comprehensive inventory of all organizational facility, site, and service-line licenses/permits/registrations, including license numbers, effective/expiration dates, scope of services, locations, and required postings.Prepare, submit, and track initial applications and renewals for facility and service-line licenses (e.g.

clinic license, CLIA, radiology, lab, DME, pharmacy and local business licenses), preventing lapses and interruptions in operations.Manage Medicare/Medicaid revalidatio...