Credentialing and Enrollment Specialist

MEDNORTH HEALTH CENTER•Wilmington, NC

1d•Onsite

About The Position

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. 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.

Requirements

High School Diploma/GED
Minimum 2 years in healthcare revenue cycle functions experience
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

Nice To Haves

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)

Responsibilities

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
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