Medical Insurance Billing and Credentialing Specialist

Job Summary:

The Medical Insurance Billing and Credentialing Specialist is responsible for ensuring that healthcare providers are properly credentialed with insurance companies, hospitals, and other healthcare organizations. This role involves managing the credentialing and re-credentialing process for medical practitioners, maintaining up-to-date and accurate records, and ensuring compliance with various regulatory requirements. The billing roles involved include data entry for charges and payments, checking claim status, and various billing projects, as needed. The ideal candidate will possess exceptional attention to detail, strong organizational skills, and the ability to manage multiple tasks simultaneously in a fast-paced healthcare environment.

Key Responsibilities:

• Credentialing and Re-credentialing:
  • Facilitate initial credentialing and re-credentialing processes for healthcare providers.
  • Prepare and submit credentialing applications and supporting documentation.
  • Track and follow up on submitted applications to ensure timely approval.
  • Verify credentials, education, training, licensure, and experience of healthcare providers.

• Database Management:
  • Maintain and update credentialing database with accurate provider information.
  • Ensure all credentialing documents are current and stored securely.
  • Monitor and track expiration dates of licenses, certifications, and other credentials.

• Compliance and Regulatory Requirements:
  • Ensure compliance with all regulatory and accrediting agency requirements.
  • Stay updated with changes in regulations and standards affecting credentialing.
  • Conduct regular audits of credentialing files to ensure completeness and accuracy.

• Communication and Coordination:
  • Serve as a liaison between healthcare providers, insurance companies, and healthcare organizations.
  • Respond to inquiries from providers and payers regarding credentialing status.
  • Communicate effectively with providers regarding missing or expiring credentials.

• Licensing:
  • Assist with License and DEA research and process
  • Respond to any questions from providers in regards to licensing applications
  • Communicate on license application progress

• Billing:
  • Charges and payments data entry
  • Obtain and document status of claims from insurance portals
  • Assist with billing team projects

• Process Improvement:
  • Identify opportunities to streamline and improve processes.
  • Implement best practices to enhance efficiency and accuracy.

Qualifications:

• Education:
  • High school diploma or equivalent required.
  • Associate’s or Bachelor’s degree in healthcare administration, business, or a related field preferred.

• Experience:
  • Minimum of 2 years of experience in medical credentialing and or licensing.
  • Familiarity with insurance, billing and healthcare industry regulations.

• Skills:
  • Strong attention to detail and organizational skills.
  • Excellent written and verbal communication skills.
  • Proficiency in Microsoft Office Suite (Word, Excel, Outlook).
  • Ability to handle sensitive and confidential information with discretion.
  • Knowledge of credentialing software and databases is a plus.

• Certifications:
  • Certified Provider Credentialing Specialist (CPCS) or Certified Professional Medical Services Management (CPMSM) preferred but not required.