Credentialing & Enrollment Specialist
Job Description
The Credentialing & Enrollment Specialist coordinates and administers provider credentialing, privileging, enrollment, and re-enrollment processes to support timely patient access, regulatory compliance, and reimbursement operations. This position maintains provider records, monitors licensure and certification requirements, manages payer enrollment activities, and ensures organizational readiness for audits and reviews. Working collaboratively with providers, leadership, Human Resources, and external agencies, the Credentialing & Enrollment Specialist helps ensure Kinston Community Health Center's providers remain properly credentialed, enrolled, and authorized to deliver services in support of the organization's mission to improve the health of our communities.
Qualifications
Education:
- High School Diploma or equivalency; Bachelor’s degree preferred
Certifications & Licenses:
- None
Experience:
- Minimum of 2 years of insurance enrollment experience in a healthcare setting, preferably in an FQHC or similar environment.
- Familiarity with credentialing requirements for HRSA, CMS, and state licensing boards.
Knowledge, Skills, Abilities:
- Strong attention to detail and organizational skills.
- Ability to establish and maintain effective working relationships
- Ability to communicate effectively both verbally and in writing
- Ability to maintain accurate, timely, and complete documentation
- Ability to maintain confidentiality and comply with HIPAA requirements.
- Proficiency in the use of clinical billing software and standard office technology
- Knowledge of provider enrollment processes and payer credentialing requirements
Essential Duties and Responsibilities
- Coordinate with Human Resources and department leaders to initiate credentialing for new providers upon hire.
- Collect and verify all necessary documents from providers (e.g., licensure, DEA, board certifications, malpractice coverage).
- Facilitate privileging and credentialing processes in accordance with KCHC policy.
- Maintain accurate, secure files and documentation for each provider.
- Monitor licensure, certifications, and other credential expirations; notify providers in advance of renewal deadlines and update files with new credentials.
- Initiate and manage the re-credentialing process at required intervals for all active providers.
- Perform periodic audits of Credentialing files and records to ensure that all required documents are collected and filed appropriately.
- Assist, as needed, with policy revisions and preparation for scheduled, periodic and ad hoc audits (i.e. OSV, FTCA, etc.)
- Set up and maintain provider profiles in credentialing databases and payer systems.
- Process and manage all initial enrollment applications and verifications in compliance with payers while ensuring completeness and accuracy
- Submit provider enrollment applications to health plans and follow up until approval is secured.
- Track application status and proactively communicate progress and issues to leadership.
- Ensure timely enrollment with Medicaid, Medicare, and commercial payers to avoid delays in billing and reimbursement.
- Track application status and proactively communicate progress and issues to leadership.
- Initiate and manage re-enrollment process at required intervals for all active providers and payers to prevent lapses.
- Complete the enrollment application for new site locations and renewal of current locations.
- All other duties as assigned.
Work Environment & Schedule
- Must be able and comfortable working in a variety of settings including, but not limited to clinical environments and office spaces.
- Must be able to work nights and weekends as departmental needs arise.
Travel Requirements
- NA
Core Competencies
- Communication: Demonstrates strong verbal, written, and digital communication skills; able to clearly explain complex information.
- Judgment & Decision-Making: Provides thoughtful input into operational and program decisions.
- Accountability & Self-Management: Works independently and efficiently, managing multiple responsibilities with minimal supervision.
- Teamwork & Collaboration: Builds effective working relationships across teams, departments, and the community.
- Problem-Solving & Initiative: Applies critical thinking and initiative to resolve issues and improve service delivery.
Service Delivery Expectations
- Demonstrates compassion and respect in all interactions, treating patients, community members, and colleagues with dignity and cultural sensitivity.
- Supports the organization’s mission to improve the health of our communities by helping ensure services, information, and resources are accessible to those we serve.
- Communicates clearly and effectively with diverse populations while actively listening and responding to community needs.
- Maintains confidentiality and handles sensitive information with professionalism and integrity.
- Upholds organizational standards, policies, and procedures while promoting high-quality service and continuous improvement.
- Demonstrates accountability and stewardship by managing time effectively, prioritizing responsibilities, and meeting deadlines.
- Shows awareness of the community served and supports initiatives that improve access to care and health education.
- Projects a professional image and collaborates with colleagues, providing guidance or leadership when coordinating activities or supporting team efforts.
- Maintains compliance with HIPAA and patient confidentiality requirements.
- Follows workplace safety standards and infection control policies when present in clinical environments.
Physical Demands
- Prolonged periods of sitting while working at a computer and viewing screens.
- Frequent use of hands and fingers for typing, writing, and operating office equipment.
- Requires close visual acuity to read screens, prepare and review documents, and assess information.
- Occasional standing and walking.
- Ability to move throughout office and clinical spaces as needed to perform job duties.
- Occasional lifting, carrying, or moving materials, equipment, or supplies weighing up to 25–50 pounds.
- Ability to communicate clearly and effectively, both verbally and in writing.
Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions of this position.
Supervisory & Leadership Responsibilities
- NA
Compliance Responsibilities
As part of Kinston Community Health Center’s commitment to ethical practices and regulatory compliance, all employees are expected to:
- Act in accordance with the KCHC Employee Handbook, policies and procedures, and all applicable federal and state laws.
- Promptly report any known or suspected violations of compliance/safety standards.
These responsibilities are essential to maintaining a culture of integrity and accountability across the organization.
Background Requirements
• Must successfully pass required background checks in accordance with organizational policy.
• Must comply with all organizational credentialing and screening requirements.