Credentialing, Compliance & Payment Posting Associate

PRINCIPAL DUTIES AND RESPONSIBILITIES:

Credentialing & Compliance

• Perform all phases of initial credentialing and re-credentialing for physicians, advanced practice providers, dentists, and other licensed or certified practitioners.
• Complete, submit, and follow up on provider enrollment and revalidation applications for Medicare, Medicaid, managed care plans, commercial insurers, and other applicable payers.
• Maintain a comprehensive credentialing and payer enrollment tracker that includes application status, effective dates, provider identification numbers, revalidation dates, participation status, and billing readiness.
• Ensure provider enrollment activities are completed timely and communicate delays, deficiencies, or risks that could affect billing or reimbursement to the CFO and appropriate leaders.
• Maintain accurate provider demographic and participation information in payer portals, CAQH, internal databases, shared files, and other applicable online systems.
• Notify payers timely of provider additions, terminations, location changes, tax identification changes, and other required updates.
• Audit payer directories and internal provider rosters for accuracy and coordinate corrections when discrepancies are identified.
• Organize and maintain confidential credentialing files, licenses, certifications, insurance documents, background information, and supporting documentation in accordance with policy and regulatory requirements.
• Conduct or support monthly 340B compliance audits, including review for potential duplicate discounts, diversion, and data integrity issues; document findings and escalate exceptions.
• Prepare credentialing, 340B, and compliance status reports for management and applicable committees, including the Quality Improvement/Risk Management Committee.
• Support internal and external audits, surveys, compliance reviews, and recertification activities by gathering and organizing requested documentation.
• Respond to internal and external credentialing correspondence promptly, generally within two business days, and resolve enrollment issues through appropriate follow-up.

Billing & Payment Posting 

• Post insurance and patient payments accurately and timely in eClinicalWorks (eCW), including electronic remittance advice (ERA), explanation of benefits (EOB), checks, electronic funds transfers (EFT), credit card payments, and other approved payment sources.
• Apply payments, contractual adjustments, denials, take-backs, recoupments, refunds, and other remittance transactions to the correct patient account, encounter, claim, payer, and service line.
• Review ERA/EOB detail to ensure payment and adjustment reason codes are posted correctly and in accordance with payer contracts, organizational policies, and established workflows.
• Reconcile daily payment posting totals to source documentation, bank deposits, EFT activity, lockbox or check logs, and remittance batches; promptly investigate and report variances.
• Identify unapplied cash, unidentified payments, duplicate payments, underpayments, overpayments, credit balances, and posting errors, and route items for resolution or correction.
• Maintain organized documentation for all payment batches and ensure each batch contains sufficient support for audit and reconciliation purposes.
• Communicate payment discrepancies, payer issues, missing remittances, and system-related concerns to the CFO, Revenue Cycle leadership, billing staff, or other appropriate personnel.
• Assist with correcting payment posting errors and reprocessing transactions in accordance with segregation-of-duties controls and authorized approval procedures.
• Support month-end close by ensuring payment batches are current, outstanding posting items are identified, and reconciliation reports are provided by established deadlines.
• Assist with insurance follow-up, account research, billing corrections, and other revenue cycle projects as workload permits and as assigned.
• Protect patient financial information and comply with HIPAA, organizational confidentiality standards, and all applicable billing and compliance requirements.

Shared Administrative and Cross-Functional

• Collaborate with Finance, Revenue Cycle, Human Resources, Operations, clinical departments, providers, and payer representatives to ensure provider billing readiness and accurate reimbursement.
• Participate in data integrity, workflow improvement, system implementation, and special projects assigned by the CFO.
• Provide cross-coverage for credentialing, payment posting, and related administrative functions as needed.
• Maintain written procedures, trackers, and desk guides for assigned responsibilities and recommend process improvements that strengthen timeliness, accuracy, accountability, and internal controls.
• Perform other duties consistent with the position as assigned by the Chief Financial Officer.