Medical Billing and Credentialing Specialist

Florida Medical Pain management Job Description

Medical Billing and Credentialing Specialist

Department: (Billing Department) -
Reports To: Revenue Cycle Manager / Controller
Location: Florida Medical Pain Management 6333 54th Ave North St. Petersburg FL 33709

Position Summary

The Medical Billing and Credentialing Specialist is responsible for managing all aspects of the medical billing process to ensure accurate, timely, and maximum reimbursement for services provided by Florida Medical Pain Management. This position requires extensive knowledge of physician and ambulatory surgery center (ASC) billing, Medicare, commercial insurance, Workers' Compensation, Personal Injury Protection (PIP), and commercial payers.

The specialist is responsible for claims submission, payment posting, denial management, appeals, insurance verification, prior authorizations, credentialing, provider enrollment, reporting, and maintaining compliance with all federal, state, CMS, HIPAA, and payer regulations.

The ideal candidate must be highly organized, detail-oriented, analytical, and capable of independently resolving complex billing and insurance issues while maintaining exceptional customer service.

Essential Job Responsibilities

Claims Management

• Prepare, review, and submit clean electronic and paper claims.
• Verify documentation supports billed services.
• Review charges for completeness and coding accuracy.
• Submit claims within payer timely filing guidelines.
• Monitor claim acceptance through the clearinghouse.
• Correct rejected claims promptly.
• Maintain communication with the clearinghouse regarding claim issues.
• Ensure claims are transmitted successfully.

Insurance Verification and Prior Authorization

• Verify patient eligibility and benefits.
• Obtain prior authorizations and referrals before procedures.
• Verify deductibles, co-insurance, copayments, and out-of-pocket responsibilities.
• Confirm medical necessity requirements are met.
• Verify Workers' Compensation and PIP claim information.

Accounts Receivable Management

• Review aging reports daily.
• Follow up on unpaid insurance claims.
• Contact insurance carriers regarding delayed payments.
• Escalate claims nearing timely filing deadlines.
• Monitor aging buckets:
• 0–30 Days
• 31–60 Days
• 61–90 Days
• Over 90 Days
• Maintain documentation of all collection activity.

Denial Management

• Review all denied claims.
• Identify denial trends.
• Correct coding or billing errors.
• Prepare reconsiderations and formal appeals.
• Submit medical records and supporting documentation.
• Track appeal status until final resolution.
• Recommend workflow improvements to reduce future denials.

Payment Posting

• Post insurance payments accurately.
• Post patient payments.
• Post contractual adjustments.
• Process refunds.
• Transfer balances appropriately.
• Reconcile deposits daily.
• Verify reimbursement complies with payer contracts.

Coding Compliance

• Review CPT, HCPCS, ICD-10-CM modifiers for accuracy.
• Ensure documentation supports billed services.
• Identify coding discrepancies.
• Stay current with CMS, Medicare, AMA CPT, NCCI edits, LCD/NCD policies.
• Work with providers regarding documentation deficiencies.

Collections

• Coordinate insurance collections.
• Monitor patient balances.
• Review payment plans.
• Assist with bad debt recommendations.
• Coordinate outside collection agency referrals when approved.

Patient Billing

• Review monthly patient statements.
• Respond to patient billing questions.
• Explain insurance benefits.
• Resolve billing disputes professionally.
• Coordinate financial hardship documentation.

Credentialing and Provider Enrollment

• Maintain provider credentialing files.
• Complete initial provider enrollment.
• Process recredentialing applications.
• Maintain CAQH profiles.
• Maintain NPI records.
• Renew provider licenses.
• Renew DEA registrations.
• Monitor board certifications.
• Enroll providers with Medicare.
• Enroll providers with Medicaid.
• Enroll providers with commercial insurance carriers.
• Track application status until completion.
• Maintain provider participation records.

Reporting

Generate and maintain reports including:

• Daily collections
• Monthly collections
• Accounts Receivable
• Insurance aging
• Denial reports
• Productivity reports
• Refund reports
• Credit balance reports
• Write-off reports
• Charge lag reports
• Payment variance reports
• Provider productivity reports
• Billing compliance reports
• Financial KPI reports

Assist management with revenue analysis and performance improvement initiatives.

Compliance Responsibilities

The employee shall maintain strict compliance with:

• HIPAA Privacy Rule
• HIPAA Security Rule
• CMS Regulations
• Medicare Billing Guidelines
• Commercial payer policies
• OIG Compliance Program
• OSHA standards
• Company Compliance Plan

Maintain complete confidentiality regarding patient information.

Policy Development

• Develop billing policies.
• Update billing procedures.
• Maintain credentialing procedures.
• Recommend workflow improvements.
• Participate in compliance audits.
• Assist with external audits.

Required Experience

• Minimum 5 years physician medical billing experience.
• 5 years experience with Personal Injury Protection (PIP). Legal compliance
• Minimum 3 years Accounts Receivable follow-up.
• Minimum 3 years denial management.
• Minimum 3 years payment posting.
• Minimum 3 years credentialing and provider enrollment.
• Preferred - Minimum 3 years Greenway Intergy experience
• Experience with Medicare.
• Experience with Workers' Compensation.
• Experience with commercial insurance billing.
• Experience with Ambulatory Surgery Center (ASC) billing .
• Experience with pain management billing strongly preferred.

Education

Required: Must

• Associate degree or higher.
• CPC, CCS-P, CPB, or equivalent coding/billing certification.

Preferred:

• Bachelor's degree.
• Additional revenue cycle certifications.

Required Knowledge

Strong understanding of:

• CPT coding
• HCPCS coding
• ICD-10-CM
• CMS guidelines
• NCCI edits
• LCD/NCD policies
• Medical necessity requirements
• EOB interpretation
• ERA processing
• Electronic claim submission
• Clearinghouse management
• Insurance contracts
• Appeals process
• Medicare regulations
• Medicaid regulations
• Commercial insurance reimbursement
• Workers' Compensation billing
• PIP billing

Technical Skills

Proficiency in:

• Greenway Intergy
• Microsoft Excel
• Microsoft Word
• Microsoft Outlook
• Electronic Health Records (EHR)
• Clearinghouse software
• Online payer portals

Core Competencies

• Excellent organizational skills
• Strong analytical ability
• Exceptional attention to detail
• Time management
• Critical thinking
• Problem-solving
• Professional communication
• Customer service
• Ability to multitask
• Independent decision-making
• Team collaboration
• Adaptability under pressure

Performance Expectations

The Billing and Credentialing Specialist is expected to:

• Submit claims within 24–48 hours of charge entry.
• Resolve claim rejections within 48 hours.
• Maintain insurance accounts receivable within established benchmarks.
• Follow up on unpaid claims every 14–21 days until resolution.
• Keep denial rates at or below departmental goals.
• Maintain provider credentialing without lapses.
• Complete payer enrollments before provider start dates whenever possible.
• Maintain accurate billing records and documentation.
• Meet productivity, quality, and accuracy standards established by Management..

Compensation

Base Salary

Compensation for this position shall be determined based on the employee's qualifications, experience, technical knowledge, certifications, demonstrated competency, productivity, work quality, and overall job performance. The Employer reserves the right to establish the starting salary and adjust compensation periodically based on performance evaluations, additional responsibilities, market conditions, and the needs of the practice.

Performance Bonus

In addition to the base salary, the employee may be eligible to participate in a performance-based bonus program.

Bonus eligibility will be determined by the Employer and may be based on one or more of the following measurable performance indicators:

• Insurance collections
• Reduction in accounts receivable
• Decrease in claim denials
• Improvement in cleaning rate
• Timely follow-up on unpaid claims
• Successful appeals and recovery of denied claims
• Credentialing and enrollment completion
• Overall revenue cycle performance
• Achievement of departmental productivity goals
• Compliance with company policies and quality standards

The specific bonus formula, collection targets, eligibility requirements, payment schedule, and performance metrics shall be established by the Employer in a separate written Bonus and Incentive Plan. The Employer reserves the right to modify, suspend, or discontinue the bonus program at any time, with or without notice, based on business needs.

Participation in the bonus program does not create a contractual right to future bonus payments, and any bonus is earned only when approved and paid by

Benefits:

• 401(k)
• 401(k) matching
• Dental insurance
• Disability insurance
• Free parking
• Health insurance
• Life insurance
• Paid time off
• Vision insurance

Work Location: In person