Job Overview
Provider Credentialing Specialist
Position Summary
The Medical Billing & Provider Credentialing Specialist is responsible for managing the complete medical billing cycle while ensuring physicians, advanced practice providers, and healthcare facilities maintain active credentialing with commercial insurance companies, Medicare, Medicaid, and other government payers. This position works closely with providers, practice leadership, and insurance carriers to maximize reimbursement, maintain regulatory compliance, and ensure uninterrupted participation with payer networks.
Essential Duties and Responsibilities
Provider Credentialing
- Coordinate initial credentialing and recredentialing for physicians and advanced practice providers.
- Complete and submit credentialing applications through CAQH, PECOS, state Medicaid portals, and commercial payer portals.
- Maintain accurate provider information within CAQH and payer databases.
- Track credentialing applications and follow up with insurance companies until approval.
- Maintain provider licenses, DEA registrations, NPI information, board certifications, malpractice insurance, and continuing education documentation.
- Monitor credential expiration dates and initiate renewals before expiration.
- Maintain credentialing files in accordance with regulatory requirements.
- Assist with provider onboarding and offboarding activities.
Facility Credentialing & Enrollment
- Complete enrollment and revalidation for clinics, ambulatory surgery centers, imaging centers, infusion centers, and other healthcare facilities.
- Maintain facility enrollment with Medicare, Medicaid, and commercial insurance carriers.
- Coordinate updates related to ownership changes, address changes, tax identification numbers, and provider affiliations.
- Ensure all facility documentation remains current and compliant.
Medical Billing
- Submit accurate electronic and paper insurance claims.
- Review and resolve claim edits and billing rejections.
- Monitor accounts receivable and follow up on unpaid or denied claims.
- Investigate, appeal, and resolve insurance denials.
- Post insurance and patient payments accurately.
- Process patient statements and assist with billing inquiries.
- Verify insurance eligibility and benefits as needed.
- Reconcile daily billing activity and maintain billing reports.
- Ensure billing complies with payer regulations and coding guidelines.
- Work collaboratively with coding staff and providers to resolve documentation issues affecting reimbursement.
Compliance & Administrative Responsibilities
- Maintain confidentiality in accordance with HIPAA regulations.
- Stay current on Medicare, Medicaid, commercial payer, and credentialing regulations.
- Prepare reports regarding credentialing status, accounts receivable, and billing performance.
- Assist with audits and payer requests.
- Develop and maintain organized provider credentialing files.
- Communicate professionally with providers, insurance companies, government agencies, and internal staff.
- Perform additional administrative duties as assigned.
Qualifications
Education
- High school diploma or equivalent required.
Experience
- Minimum of 2 years of provider credentialing and enrollment experience preferred.
- Experience with Medicare, Medicaid, and commercial payer credentialing.
- Experience credentialing physicians, nurse practitioners, physician assistants, and healthcare facilities preferred.
Knowledge & Skills
- Strong understanding of medical billing processes and revenue cycle management.
- Knowledge of ICD-10-CM, CPT, and HCPCS coding principles.
- Experience with provider enrollment systems including CAQH, PECOS, NPPES, and state Medicaid portals.
- Knowledge of CMS regulations and commercial insurance credentialing requirements.
- Proficiency with electronic health records (EHR) and practice management software.
- Excellent organizational and time management skills.
- Strong analytical and problem-solving abilities.
- Exceptional written and verbal communication skills.
- Ability to manage multiple deadlines with minimal supervision.
- Proficiency in Microsoft Office Suite, including Excel, Word, and Outlook.
Preferred Certifications
- Certified Professional Biller (CPB)
- Certified Professional Coder (CPC)
- Certified Medical Reimbursement Specialist (CMRS)
- Certified Provider Credentialing Specialist (CPCS)
Physical Requirements
- Prolonged periods of sitting and computer work.
- Ability to lift up to 20 pounds occasionally.
- Ability to perform repetitive keyboard and mouse functions.
Work Environment
- Office-based healthcare environment.
- Occasional interaction with physicians, clinical staff, insurance representatives, and regulatory agencies.
- Fast-paced setting requiring attention to detail, confidentiality, and the ability to prioritize multiple responsibilities.
Compensation:
· Negotiable, DOE
Pay: $18.00 - $20.00 per hour
Benefits:
- Health insurance
- Paid time off
Work Location: In person
