Medical Credentialing Specialist

Join Claim.MD: Simplifying Healthcare Through Innovation and Compassion
Claim.MD is a leading national electronic healthcare clearinghouse, supporting thousands of providers, payers, and software vendors across the country. Our mission is to simplify and optimize the flow of medical claims and related data, enabling healthcare organizations to operate more efficiently and deliver better patient outcomes. We are dedicated to streamlining healthcare transactions and improving operational efficiency for our users. Driven by a strong commitment to innovation and excellence, we seek individuals who are passionate about making a tangible difference in the healthcare industry.

Why You Will Love Working Here 

• Collaborative Culture - Work alongside a team that values open communication, mutual respect, and shared success.
• Growth Opportunities - We invest in your professional development, offering training and pathways to advance your career.
• Flexible Work Environment - Enjoy the benefits of a work-from-home environment that supports work-life balance.
• Meaningful Impact - Contribute to a product that directly improves the efficiency of healthcare providers nationwide. 

What We Offer

• Compensation Range - $76,000- $86,000 annually, based on experience and geographic location. Final compensation will be determined in accordance with state-specific pay transparency requirements.
• 4-Day (32-hour) Workweek - Full-time, exempt role with a 32-hour weekly schedule.
  
• Comprehensive Benefits Package - Including health, dental, and vision coverage, as well as retirement savings plan.
• Internet Reimbursement - Up to $100 per month for high-speed internet required for the role.
• Career Growth and Development - Opportunities for skill-building, advancement, and continuous learning.
• Work-Life Balance - Flexible schedules and a supportive, collaborative work environment
• Inclusive Company Culture - A commitment to diversity, equity, and inclusion in all our practices.
• Employee Wellness - Programs and resources focused on your overall well-being, including mental and physical health support.
• Work Remotely - Opportunity to work remotely.
• Paid-Time Off - Ten days of paid time off, in addition to a generous holiday schedule, to support your work-life balance and personal well-being.

About the Role 
The Medical Credentialing Specialist is responsible for researching, documenting, and maintaining the operational and regulatory requirements governing provider credentialing and enrollment across commercial, government, and managed care payers. This role manages credentialing resources and operational documentation that support consistent, accurate, and compliant provider enrollment activities.

Operating at the intersection of credentialing operations, payer requirements, regulatory compliance, and process management, the Medical Credentialing Specialist serves as a subject matter expert on provider credentialing standards and operational practices. This role evaluates credentialing requirements, monitors regulatory and payer changes, maintains operational documentation, and partners with internal stakeholders to support consistent, efficient, and compliant credentialing operations.

Essential Functions and Responsibilities
The following duties are considered essential to the successful performance of this position. These responsibilities are central to supporting operational excellence, maintaining compliance, and developing scalable credentialing resources that support Claim.MD's healthcare operations. 

• Credentialing Research & Knowledge Management
  • Research, interpret, and maintain provider credentialing and enrollment requirements for commercial, Medicare, Medicaid, and other payer organizations.
  • Analyze payer credentialing policies, provider manuals, enrollment guides, and regulatory resources to identify operational requirements, workflow considerations, and business impacts.
  • Manage credentialing documentation, operational references, and internal knowledge resources that support consistent business practices.
  • Organize credentialing resources, including payer requirements, documentation standards, operational guidance, timelines, and reference materials.
  • Periodically review credentialing resources to ensure information remains current, accurate, and aligned with evolving payer requirements and regulatory guidance.
• Payer Requirements and Operational Documentation
  • Maintain documentation addressing payer-specific credentialing requirements, enrollment prerequisites, revalidation schedules, and submission processes.
  • Evaluate payer-specific credentialing requirements to identify operational differences, documentation needs, and workflow impacts.
  • Standardize and enhance operational reference materials outlining payer workflows, documentation requirements, processing expectations, and operational considerations.
  • Ensure credentialing documentation remains accurate, organized, and audit-ready.

• Regulatory Monitoring and Compliance
  • Monitor federal, state, and payer-specific regulatory changes affecting provider credentialing and enrollment.
  • Evaluate regulatory updates for operational impact and recommend appropriate documentation or process revisions.
  • Maintain working knowledge of CMS guidance, state Medicaid enrollment requirements, CAQH processes, NPPES, PECOS, and other applicable credentialing standards.
  • Support internal compliance initiatives by ensuring credentialing documentation accurately reflects current regulatory expectations.
• Operational Process Improvement
  • Evaluate credentialing processes to identify opportunities for improved consistency, efficiency, and operational effectiveness.
  • Maintain and refine operational documentation, workflow resources, reference guides, and supporting materials related to credentialing activities.
  • Recommend enhancements to credentialing processes, documentation standards, and operational practices.
  • Support continuous process improvement initiatives that strengthen operational quality, documentation consistency, and business efficiency.
  • Promote standardized operational practices that support consistent credentialing activities across the organization.
    

• Cross-Functional Collaboration
  • Partner with Payer Relations, Support Services, Development, Privacy & Compliance, and other internal stakeholders to ensure credentialing requirements are accurately reflected within operational processes and documentation.
  • Collaborate on initiatives involving provider onboarding, payer operational changes, credentialing activities, and business process improvements.
  • Provide credentialing subject matter expertise to support operational decisions, documentation updates, and workflow refinement.
  • Promote alignment across departments by supporting consistent credentialing practices and documentation standards.
    
• Subject Matter Expertise
  • Serve as an internal subject matter expert regarding provider credentialing standards, payer enrollment requirements, and industry best practices.
    Interpret complex credentialing requirements and translate them into practical operational guidance and documentation.
  • Maintain awareness of emerging credentialing trends, regulatory developments, and evolving payer practices.
  • Provide recommendations that strengthen operational consistency, documentation quality, and credentialing readiness.
    

Required Skills and Competencies

• Provider Credentialing Expertise – Thorough understanding of provider credentialing, enrollment, revalidation, and payer participation requirements across commercial and government health plans.
• Credentialing Systems Knowledge – Experience utilizing credentialing platforms including CAQH ProView, PECOS, NPPES, state Medicaid portals, and commercial payer enrollment systems.
• Healthcare Regulatory Knowledge – Understanding of CMS regulations, credentialing standards, payer enrollment requirements, and healthcare regulatory frameworks affecting provider participation.
• Research & Information Analysis – Ability to interpret complex payer requirements, regulatory guidance, and operational documentation and translate findings into clear internal resources.
• Documentation & Knowledge Management – Ability to organize, maintain, and continuously improve comprehensive credentialing documentation supporting operational consistency and audit readiness.
• Critical Thinking & Operational Judgment - Ability to evaluate complex credentialing requirements, identify operational implications, and recommend practical, compliant solutions.
• Operational Process Improvement – Ability to identify process improvements, standardize documentation, and support scalable credentialing operations.
• Communication & Stakeholder Collaboration – Communicates effectively with internal teams, payer representatives, and regulatory organizations while supporting cross-functional initiatives.
• Compliance Awareness – Understands the importance of HIPAA, PHI protection, credentialing documentation integrity, and regulatory compliance.

Required Experience

• Education - A high school diploma, GED, or equivalent is required.
• Professional Experience - A minimum of five (5) years of progressive experience in medical credentialing, payer enrollment, or healthcare revenue cycle operations, preferably within:
  • A medical clearinghouse
  • A billing or revenue cycle management (RCM) firm
  • A multi-specialty provider group or managed care organization

• Credentialing Systems and Processes - Demonstrated experience managing provider credentialing workflows using systems such as:
  • CAQH ProView, PECOS, NPPES, and commercial payer portals
  • Tracking systems for expiration dates, revalidation, or regulatory audits
    
• Regulatory & Industry Knowledge - Working familiarity with national and state-level payer enrollment standards, including:
  • Medicare/Medicaid guidelines (CMS)
  • State-by-state enrollment protocols and revalidation timelines
  • Internal auditing, reporting, and compliance support documentation
    

• Cross-Functional Collaboration - Proven experience partnering with internal departments (e.g., Development, Privacy & Compliance) and external stakeholders (e.g., payers, regulatory bodies) to solve complex credentialing issues and improve processes.
• Remote Operations Experience - Prior success in a remote or distributed work environment with the ability to independently manage time, communication, and output expectations across multiple projects or stakeholders.

Preferred Skills and Competencies

• Education - Associate or Bachelor’s degree in Healthcare Administration, Health Information Management, Business Administration, or a related field preferred, or equivalent professional experience. 
  
• Professional Experience 
  
  • Experience supporting credentialing operations within a healthcare clearinghouse, revenue cycle management organization, managed care organization, or multi-specialty provider group.
    
  • Experience maintaining or improving standard operating procedures (SOPs), operational documentation, training materials, or process guides.
    
  • Experience working directly with payer credentialing departments, provider enrollment teams, or regulatory organizations.
    
  • Experience supporting credentialing audits, compliance initiatives, or quality improvement programs.
    
  • Working knowledge of state-specific provider enrollment requirements and credentialing variations across multiple jurisdictions.
    

Work Environment and Expectations
To be considered for this position, applicants must currently reside in the United States and be authorized to work on a full-time basis. Claim.MD is unable to sponsor or take over sponsorship of employment visas at this time. 

Candidates must be willing to submit to a pre-employment background check conducted in accordance with applicable federal, state, and local laws. Employment at Claim.MD is contingent upon the successful completion of this background screening process.

• This is a fully remote role operating across all U.S. time zones; however, Eastern Time (EST) availability is preferred to best support current team needs.Employees are expected to work from a quiet, dedicated and secure home workspace (mobile or on-the-go work is not supported for this role).
• Company-issued desktop equipment will be provided.
• Employees must be able to sit and use a computer and phone for extended periods.
• Employees are expected to maintain a reliable high-speed internet connection and to be available during core collaboration hours

Claim.MD is committed to creating an accessible and inclusive workplace. In accordance with the Americans with Disabilities Act (ADA), we provide reasonable accommodations to qualified individuals with disabilities. If you require accommodation during any stage of the application for the employment process, please contact Claim.MD’s HR Department. We are happy to provide support to ensure equal opportunities throughout the hiring and onboarding experience.

E-Verify Participation
Claim.MD participates in the federal E-Verify program to confirm the identity and employment eligibility of all newly hired employees. As a participant in E-Verify, Claim.MD will provide the Social Security Administration (SSA) and, if necessary, the Department of Homeland Security (DHS), with information from each new employee’s Form I-9 to confirm work authorization.

Federal law requires all employers to verify the identity and employment eligibility of all persons hired to work in the United States. Claim.MD will not use E-Verify to pre-screen job applicants or to reverify current employees and will not discriminate based on race, color, religion, sex, national origin, age, disability, or any other protected status during the E-Verify process.

For more information about E-Verify, please visit www.e-verify.gov.

Commitment to Inclusion
At Claim.MD, we believe in a skills-first approach to recruitment and employment. This means focusing on what you can do and how you can grow, rather than traditional metrics alone. We are committed to adhering to anti-exclusion practices, removing barriers to access, and enhancing opportunities for all individuals based on merit and potential. 

Your skills, experiences, and perspective are valuable - and we want to empower you to make your mark here with us. 

Equal Employment Opportunity
Claim.MD is proud to be an equal opportunity employer. We celebrate diversity and are committed to creating an inclusive environment for all employees and applicants regardless of race, color, religion, sex, national origin, age, disability, veteran status, sexual orientation, gender identity, or any other legally protected status.

Interested in applying? Submit your application. We look forward to welcoming you!