The Licensing and Credentialing Specialist helps us achieve our Mission by ensuring our clinicians are properly credentialed, licensed, and enrolled in payor networks to care for our patients. The responsibilities include timely submission of new and renewal licensing requests, credentialing of Ophelia’s providers, and the enrollment of Physicians, Nurse Practitioners, and Physician Assistants in managed care organizations and government payors such as Medicare and Medicaid, as well as many commercial plans. The L&C Specialist also maintains accurate provider records within various databases, including CAQH and payer portals.

The L&C Specialist works with a team of other specialists and collaborates closely with Clinical Operations, Billing, and Contracting teams to ensure our patient care functions smoothly. The role reports to the Licensing and Credentialing Senior Manager.

In this role, you will:

• Review provider initial and reappointment credentialing applications, ensuring compliance with industry standards.
• Conduct primary source verification and coordinate the credentialing committee review process
• Ensure new and renewed license, DEA, and CSR requests are submitted promptly.
• Follow up directly with providers to gather missing or incomplete information for enrollment submissions.
• Submit enrollment packets to payers (MCOs, Medicare, Medicaid) in an accurate and timely manner.
• Monitor enrollment status and address any delays by following up with payers to expedite credentialing approvals.
• Enter and maintain accurate provider enrollment data in internal and external databases, including CAQH and payer portals, by updating demographic information, practice locations, termination of providers, and other maintenance forms as required.
• Act as a point of contact between providers, payors, and internal teams to resolve issues related to credentialing, enrollment, and reimbursement.

The Ideal candidate will have:

• Associates degree or equivalent combination of education and experience
• 3-5 years of working experience in a credentialing and enrollment setting required
• Knowledge of multi-state/national provider credentialing and/or enrollment required
• Experience with PECOS/Medicare and or state Medicaid enrollment platforms
• Knowledge of Google Workplace/Microsoft office or other task management suites
• National Association of Medical Staff Services (NAMSS) Certified Provider Credentialing Specialist (CPCS) certification a plus

Our Benefits Include:

• Remote work anywhere in the United States
• Competitive medical, vision, and health insurance (many plans are fully covered for the employee!)
• 20 days of PTO per year
• 10 company holidays
• 401k Contribution Platform
• Additional benefits offered through our benefits provider such as life insurance, short and long term disability, financial wellness, virtual primary care, among others!

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