Credentialing Specialist with Medical Billing and AR Support

The Credentialing Specialist is primarily responsible for managing all facets of the healthcare provider credentialing, re-credentialing, privileging, and payer enrollment processes. This role ensures that all providers are properly vetted, authorized to practice, and successfully enrolled with insurance payers to facilitate timely reimbursement, with secondary duties supporting Accounts Receivable functions.

Primary Duties and Responsibilities: Credentialing

• Initial Credentialing & Reappointment: Manage the complete credentialing lifecycle for all practitioners, including initial applications and timely reappointment/re-credentialing.
• Collect, organize, and thoroughly review all required documents (licenses, certifications, education, malpractice history, etc.).
• Perform Primary Source Verification (PSV) of all credentials according to delegated and internal policies.
• Payer Enrollment & Maintenance:
• Prepare, submit, and diligently track provider enrollment applications (initial setup, changes, terminations) with Medicare, Medicaid, and all commercial insurance carriers.
• Ensure NPI, CAQH, PECOS, and state enrollment profiles are accurate, current, and attested to promptly.
• Database Management: Accurately enter and maintain all provider credentialing, privileging, and payer enrollment data in the credentialing software (e.g., Cactus, MD-Staff, Symplr).
• Compliance & Audits:
• Maintain current knowledge of state/federal regulations, medical staff bylaws, and accreditation standards (e.g., NCQA, TJC) related to credentialing and provider enrollment.
• Assist in preparing for and participating in external payer or accreditation audits.
• Expirables Management: Proactively monitor and track all provider expiration dates (licenses, DEA, certifications, insurance), ensuring timely renewal processes are initiated to prevent lapses in coverage or billing capacity.
• Committee Support: Prepare files and relevant documentation for Credentialing Committee review and meetings.

Secondary Duties: AR Support

• Payer Communication: Serve as a liaison between the revenue cycle team and insurance payers regarding provider enrollment issues that impact claim processing.
• Denial Resolution: Assist the billing team by quickly resolving claim denials or rejections directly tied to credentialing or provider enrollment errors (e.g., "provider not on file," "invalid provider number").
• Data Integrity: Verify that provider demographic information is consistent across the credentialing system, billing system, and payer enrollment portals.

Qualifications and Skills

Required Skills

• Expert Knowledge: Deep, working knowledge of the credentialing process, PSV requirements, and payer enrollment procedures.
• Technology: Proficient in using specialized credentialing software (required) and familiarity with electronic health record (EHR) and medical billing systems (preferred).
• Compliance & Detail: Exceptional organizational skills and meticulous attention to detail to handle highly sensitive and regulated documentation.
• Interpersonal Skills: Professional and effective communication skills to interact with providers, internal leadership, and external payer contacts.

Education and Experience

• Minimum of 1 to 3 years of dedicated experience in healthcare provider credentialing, preferably in a group practice, hospital, or managed care setting.
• Associate's or Bachelor's degree in Healthcare Administration or a related field is preferred.
• Certification (Highly Preferred): Certified Provider Credentialing Specialist (CPCS).

Job Type: Full-time

Pay: Rs35, Rs55,000.00 per month

Experience:

• credentialing: 1 year (Preferred)

Work Location: In person