Credentialing and Enrollment Specialist

Mednorth Health Center•Wilmington, NC

8h•Onsite

About The Position

This position is primarily responsible for credentialing and enrollment (70%) and billing (30%). The Credentialing/Enrollment Specialist will review and authenticate credentials, qualifications, licenses, and certifications, and manage the enrollment of facilities and providers with contracted payors. The Billing Specialist will handle all aspects of 1500 and UB claims, including claim creation, follow-up, and correspondence with providers, insurance inquiries, and patients, aiming to maximize revenue and identify process improvements. The role operates within an office environment and requires adherence to organizational policies and procedures.

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 have 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

1 year credentialing/enrollment experience
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 enrollment information within Federal and State guidelines for all providers and clinics utilizing credentialing software.
Onboard new providers for credentialing by creating provider files and initiating communication through credentialing software.
Assist new providers in obtaining information such as an NPI, Taxonomy, CAQH files, and attest for each provider every 90 days.
Ensure 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.
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.
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.
Perform reporting needs to meet organization needs within credentialing software.
Work with the department to resolve claims issues regarding credentialing and enrollment, including ongoing communication with payers.
Prepare and submit clean claims to third-party payers either electronically or by paper, following billing guidelines and legal requirements.
Respond to inquiries from patients, payers, providers, and/or other staff.
Identify and resolve patient/insurance billing issues.
Work closely with team members regarding claim appeals, denials, and resolution.
Perform and monitor all steps in the billing processes to ensure maximum reimbursement.
Understand and adhere 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.
Maintain all targets (KPIs) in the Revenue Cycle Department.
Deliver the highest quality service to internal and external customers.
Assist other members of the team with projects as needed.
Maintain strict confidentiality and adhere to all HIPAA guidelines/regulations.
Adhere to the Mission and Values of MNHC.
Other duties as assigned by management.