Billing and Credentialing Specialist

Position Summary:

The Billing and Credentialing Specialist is responsible for overseeing insurance billing processes, managing provider credentialing and re-credentialing with payers, and ensuring compliance with relevant regulations and payer requirements. This role works closely with clinicians, administrative staff, and insurance companies to support the financial and operational health of the organization.

Essential Job Functions:

• Claim Preparation & Submission: Prepare and submit accurate and timely medical claims to insurance companies, government programs, and other payers.
• Charge Entry: Accurately enter charges into the billing system based on patient services and coding information.
• Payment Posting: Post payments received from payers and patients to the appropriate accounts, ensuring accuracy in the allocation of funds.
• Denial Management: Review and analyze claim denials, identify the reasons for denial, and take appropriate action to correct and resubmit claims.
• Billing Audits: Perform regular audits of patient accounts to ensure accuracy in billing and coding, and identify any discrepancies or errors.
• Patient Billing: Generate and send out patient statements, responding to patient inquiries regarding their bills, and providing clear explanations of charges and payment options.
• Insurance Verification: Verify patient insurance coverage and benefits prior service delivery and claim submission, ensuring that all necessary information is obtained and recorded.
• Compliance: Ensure all billing activities comply with federal, state, and local regulations, as well as internal policies and procedures.
• Reporting: Assist in generating reports on billing activities, accounts receivable, write-off recommendations and other key metrics for review by the Revenue Cycle Manager.
• Collaboration: Work closely with the coding team, accounts receivable specialists, and other departments to resolve billing issues and ensure a seamless revenue cycle process.
• Process Improvement: Identify opportunities to streamline billing processes and improve efficiency, making recommendations to the Revenue Cycle Manager.
• Verification of accuracy of CPT/HCPCS and ICD-10 codes, units, and modifiers prior to claim submission.
• Maintain confidentiality of client records in accordance with HIPPA standards

Credentialing Duties:

• Manage initial credentialing and re-credentialing of clinicians with commercial insurance payers, Medicaid, Medicare, and relevant licensing boards.
• Track and maintain current credentials, licenses, certifications, and insurance documents for all clinical staff.
• Prepare and submit credentialing applications and follow up with payers to ensure timely approval.
• Maintain credentialing software or databases and generate compliance reports as needed.
• Ensure compliance with NCQA, HIPAA, and payer-specific requirements.
• Coordination with HR to collect required licensure, certification, and supporting documentation.
• Provide guidance and training to staff regarding documentation requirements for accurate billing,
• Maintain provider information in internal and external databased (CAQH, PECOS, NPPES).

Essential Qualifications:

• Technical Skills: Proficiency in medical billing software, electronic health records (EHR), and Microsoft Office Suite. Experience with [specific billing software] is a plus.
• Knowledge: Strong understanding of medical billing and coding procedures, insurance claim submission, and payer requirements.
• Attention to Detail: High level of accuracy and attention to detail in processing claims and posting payments.
• Communication Skills: Excellent verbal and written communication skills, with the ability to interact effectively with patients, payers, and team members.
• Problem-Solving Skills: Strong problem-solving abilities with a focus on resolving billing issues and ensuring accurate claim submission.
• Organizational Skills: Ability to manage multiple tasks, prioritize workload, and meet deadlines in a fast-paced environment.
   

Education:

• High school diploma or equivalent required. An associate's or bachelor's degree in healthcare administration, business, or a related field is preferred.
   

Experience and Competencies:
 

• Minimum of 2 years of experience in medical billing or a related field.
   

Working Conditions:

• Environment: Office setting, with regular use of computers and telephones.
• Hours: Typical work hours are Monday to Friday, with occasional after-hours work as needed.

Essential Physical and Mental Demands of the Job

• The employee must be able to perform the following essential duties and activities with or without accommodation:
   

Physical Demands:

• Requires mobility and physical activity: Having an adequate range of body motion and

mobility to work in an office, residential, or outdoor environment including standing and

walking (even and uneven surfaces), sitting for extended periods of time, bending,

twisting, reaching, balancing, occasional lifting and carrying of up to 50 pounds. Use of

computer and telephone systems is required which includes coordination of eye and

hand, and fine manipulation by the hands (typing, writing, and working with files).

• Requires the ability to defend oneself and clients in physically abusive situations

through the use of approved physical de-escalation techniques.

• Requires talking: Expressing or exchanging ideas by means of the spoken word. Talking

is required to impart oral information to employees, clients, patients, and the public, and in those activities in which the employee is required to convey detailed or

important spoken instructions to others accurately, loudly, or quickly.

• Requires hearing: Hearing is required to receive and communicate detailed information

through oral communication.

• Requires seeing: Clarity of vision at 20 inches or less and at distance. This factor is

required to complete paperwork for many of the employee’s essential job functions and

to observe client behavior and activities in and out of the facility.

• The normal work routine involves no exposure to human blood, body fluids or tissues.

However, exposure or potential exposure may be required as a condition of

employment. Appropriate personal protective equipment will be readily available to

every employee.

Mental Demands:

• Requires the ability to collect and analyze complex numerical and written data and

verbal information to reach logical conclusions.

• Requires the ability to work and cooperate with clients, co-workers, managers, the

public and employees at all levels in order to exchange ideas, information, instructions

and opinions.

• Requires the ability to work under stress and in emotionally charged settings.
• The ability to defend oneself and clients in mentally/verbally abusive situations through

the use of approved mental/verbal de-escalation techniques.