Credentialing and Enrollment Specialist

JOB SUMMARY:

70% - Credentialing/Enrollment Specialist

The Credentialing/Enrollment Specialist is responsible for reviewing and authenticating credentials, qualifications, licenses, certifications, and other relevant documents submitted by individuals and the organization. And enrollment of all facilities and providers enrollments with all contracted payors.  

30% - Billing Specialist

The Billing Specialist is responsible for all aspects of billing 1500 and UB claims. The Billing Specialist, a key position in the Revenue Cycle, facilitates the claims process, including accurate and timely claim creation, follow-up and correspondence with providers, insurance inquiries and patients. The incumbent will assist in the clarification and development of process improvements and inquiries to maximize revenues.

Work is performed in an office environment. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements for this job description are not intended to be all inclusive. They represent typical elements considered necessary to successfully perform the job.

REPORTING RELATIONSHIPS:                                                                

The position reports to the Revenue Cycle Manager. No staff report to this position.

JOB DUTIES AND ESSENTIAL FUNCTIONS:

Credentialing and Enrollment:

• Oversee and maintain all credentialing, recredentialing, and enrolment information within Federal and State guidelines for all providers and clinics utilizing credentialing software, with the utmost accuracy and attention to detail
• Onboarding new providers for credentialing by creating provider files and initiating communication to providers through credentialing software
• Assist new providers in obtaining information such as an NPI, Taxonomy, CAQH files, and attest for each provider every 90 days
• Responsible for ensuring all new providers are oriented to coding, billing, and documentation compliance
• Track all licenses and appropriate credentials and communicate with providers regarding license expirations and renewals in a timely manner
• Maintain databases such as CAQH, NC Tracks, Medicare and commercial insurance with correct and up to date information
• Maintain insurance participation with insurances using rosters, making corrections when needed based on internal changes and payor rules
• Maintain and track progress in credentialing software for payor enrollments for all providers
• Notify and update all pertinent insurances when there is a license change for a provider
• Preform reporting needs to meet organization needs within credentialing software
• Work with department to resolve any claims issues regarding credentialing and enrollment. To include ongoing communication with payers to ensure correct reimbursement of all affected claims

Billing:

• Prepares and submits clean claims to third party payers either electronically or by paper.
• Follows billing guidelines and legal requirements to ensure compliance with federal and state regulations.
• Respond to inquiries from patients, payers, providers, and/or other staff as requested.
• Identifies and resolves patient/insurance billing issues.
• Work closely with team members regarding claim appeals, denials, and resolution.
• Performs and monitors all steps in the billing processes to ensure maximum reimbursement from patients, government, and commercial payers.
• Understands and adheres to Medicare, Medicaid and other commercial payer rules and regulations applicable to billing.
• Use online healthcare databases and other resources for verification and claim status.
• Maintains all targets (KPIs) in Revenue Cycle Department.
• Deliver the highest quality service to internal and external customers.
• Assist other members of the team with projects as needed.
• Maintains strict confidentiality; adheres to all HIPAA guidelines/regulations.
• Other duties as assigned by management.
• Adhere to the Mission and Values of MNHC

QUALIFICATIONS:

• High School Diploma/GED
• Minimum 2 years in healthcare revenue cycle functions experience
• Preferred 1 year credentialing/enrollment experience
  • Special consideration will be given to those who have a certificate from:
    • NAMSS: Certified Professional Enrollment Specialist (CPES) or Certified Professional Credentialing Specialist CPCS)
    • Decision Health: Provider Enrollment Specialist Certificate (PESC)
    • AAPC: Credentialing Specialist
    • ArchPro: Community Health Credentialing Specialist (CH-CS)
• Maintain a strong and working knowledge of credentialing and enrollment rules, regulations, and processes
• Experience with payor enrollment for facilities, LICP, and OLICP
• Knowledge of Credentialing/Enrollment Software.
• Accurate and precise attention to detail
• Excellent verbal and written communication skills
• Must be focused, self-directed, organized, and strong problem-solving abilities
•  ICD-10, CPT/HCPCS codes, medical terminology, and billing processes
• Knowledge of Medical Billing/EHR (Electronic Health Records)
• Knowledge of EOBs, EFTs and ERAs
• Knowledge of Microsoft Office software
• Able to work both independently and as part of a team

PHYSICAL DEMANDS:

The physical demands described herein are representative of those that must be met by an employee to successfully perform the essential functions of this job.  Reasonable accommodation will be made to enable individuals with disabilities to perform the essential functions. While performing the duties of this job, the employee is regularly required to stand, walk, talk, and hear, use hands to finger, handle or feel. The employee is occasionally required to stoop, kneel, crouch or crawl. The employee is frequently required to lift and/or move up to 20 pounds. The special vision requirements for this job are close vision (clear vision at 20 inches or less), color vision (ability to identify and distinguish colors).

WORK ENVIRONMENT:

 The work environment characteristics described herein are representative of those an employee encounters while performing the essential functions for this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

MedNorth Health Center provides comprehensive health care services, inside a multi-cultural medical/dental clinic, to all individuals; insured, uninsured, and underinsured. The building is heated in winter and air conditioned in the summer with noise levels of moderate to loud. We serve patients who speak multiple languages and who may need the assistance of an interpreter. In this position one may be subject to exposure to copier toner, correction fluid, bright fluorescent lighting, and continuous personal computer exposure.

This job is a Blood borne Pathogen’s risk category III position.

GENERAL EXPECTATIONS:

• The employee is expected to attend work on a daily basis and to be at work on time.
• The employee is expected to be a team player.
• The employee is expected to report absences in accordance with personnel policies and procedures.
• The employee’s work is expected to be accurate, neat, and thorough, and completed on time.
• The employee is expected to have a positive attitude, be cooperative, and considerate of others.
• The employee is expected to be dependable and is expected to accept responsibility for assignments and duties given.
• The employee is expected to dress and act in a professional manner and to adhere to all safety standards.
• The employee is expected to participate in staff meetings, be courteous and polite with patients and other staff.
• The employee is expected to maintain confidentiality.