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).