RCM Credentialing Specialist

Overview

PracticeSuite, Inc. is an innovative platform to enable medical practices and other healthcare facilities to create an amazing patient experience. As a single platform, PracticeSuite has diverse features to modernize practices and take them to the next level.

PracticeSuite is currently in search of our newest Team Member who is passionate about providing outstanding customer service to our customers. We are looking for an individual seeking a career opportunity with one of the fast-growing cloud computing software company in the country.

We are looking for a Credentialing Compliance Specialist on the RCM and Provider side, this position will perform administrative and technical tasks pertaining to credentialing new providers and maintaining credentials for current providers.

Role & Responsibilities

• Manage the end-to-end credentialing and re-credentialing process for providers with Medicare, Medicaid, and major commercial insurance payers.
• Submit and track provider enrollment applications, group contracts, and facility participation agreements with federal and private payers.
• Maintain and update CAQH profiles, NPPES, PECOS, Availity, and other portals with accurate provider information.
• Work closely with payers to ensure credentialing timelines and compliance with state, federal, and payer-specific regulations.
• Develop, maintain, and enhance the company's corporate compliance program, with a strong focus on HIPAA, HITECH, CMS guidelines, and SaaS-specific data security standards (e.g., SOC 2).
• Conduct periodic risk assessments and audits of RCM operations, including billing, coding, claims management, and client contracts.
• Monitor compliance with federal and state healthcare regulations, including OIG guidance, False Claims Act, and Anti-Kickback Statute.
• Serve as a subject matter expert (SME) for cross-functional teams (e.g., Product, Engineering, Client Success) regarding compliance risks, controls, and best practices.
• Lead compliance onboarding and training for internal teams and provide guidance on policy updates.
• Collaborate with internal IT/security teams to ensure the SaaS platform meets ongoing privacy and data protection standards (e.g., HIPAA, GDPR, SOC 2, ISO 27001).
• Monitor and manage credentialing expirable (e.g., licenses, DEA, malpractice insurance) and ensure timely renewals.
• Communicate effectively with providers, practice managers, billing teams, and payers to resolve enrollment issues and delays.
• Keep internal systems updated with current credentialing status and documentation for audits and claims submission readiness.
• Ensure compliance with industry standards including CMS guidelines, NCQA, URAC, and HIPAA.
• Identify and coordinate any risk management, substance abuse and/or malpractice issues. Reviews files for any "red flag" concerns.
• Maintains strict confidentiality of all records, data and occurrences as condition of initial and/or continued employment.

Qualifications

• 2–4 years of payer credentialing experience in an RCM, MSO, or medical group setting.
• Comprehensive understanding of federal payer systems (Medicare/PECOS, Medicaid) and major commercial payers.
• Experience managing multi-state enrollments and working with provider rosters.
• Proficiency with credentialing platforms and payer portals (CAQH, PECOS, NPPES, Availity).
• Strong communication, documentation, and organizational skills.
• 5+ years in a compliance role within a revenue cycle organization
• Strong knowledge of HIPAA, HITECH, CMS billing requirements, and relevant fraud and abuse laws (FCA, AKS).
• Familiarity with SaaS platform compliance, such as SOC 2, HITRUST, or ISO 27001 frameworks.
• Ability to handle a high volume of applications and meet tight deadlines.
• Exceptional communication and telephone skills required, as well as a great deal of patience and understanding.
• Experience working with physicians and/or senior executives preferred.
• Possess a high level of self-confidence and persistence; maintain an assertive approach in dealing with providers.
• Must possess excellent organizational skills and the ability to multi-task effectively.
• Demonstrate the ability to prioritize heavy workload and work independently with minimal supervision.
• Proficient computer and internet skills; familiarity with Microsoft Office software required.
• Knowledge of medical terminology preferred.
• Will develop in-depth knowledge of department and company internal workflows including, but not limited to individual state's procedures and negotiating protocols.

Who We Are

PracticeSuite is a national, fast-growing cloud computing software company based in Tampa, FL that provides a cloud-based 360°Office Platform to healthcare facilities. PracticeSuite has an agile management team, high employee morale, and high customer satisfaction and retention. PracticeSuite is growing rapidly and is being recognized as one of the 5 top cloud-based systems within healthcare.

Please visit our website to learn more about us, at www.practicesuite.com

PracticeSuite, Inc is committed to equal opportunity in the terms and conditions of employment for all employees and job applicants without regard to race, color, religion, sex, sexual orientation, age, gender identity or gender expression, national origin, disability or veteran status. PracticeSuite, Inc also complies with all applicable national, state and local laws governing nondiscrimination in employment.