Billing and Credentialing Specialist

The Billing & Credentialing Specialistis responsible formanaging the full revenue cycle for infusion services, including benefits investigation, verification,accurateclaim submission, denial resolution, and AR follow-up. This role handles complex buy-and-bill infusion billing , including J-codes, S-codes, NDC crosswalks, biologics, and time-based infusion services.

Additionally, the specialist manages provider credentialing and enrollment with Medicare, Medi-Cal, and commercial payers, ensuring compliance andtimelyactivation. The position supports patients, providers, and internal departments tooptimizereimbursement andmaintaincontinuity of care.

Key Accountabilities:

Medical Benefits Billing & Revenue Cycle Management

Verify medical benefits for infusion services, including specialty biologics, IVIG, and injectable therapies.

Complete detailed benefit investigation (BI) for medical benefits , deductible, OOP, copay, and coverage limitations.

Process, correct, andsubmitclaims using CMS-1500 and UB-04 forms for facility and professional billing.

Apply proper coding for infusion services including:

J-codes / S-codes

NDC conversions & crosswalks

Infusion CPT codes (96365–96379, 96401–96417)

Manage buy-and-bill billing including ASP pricing, wastage documentation, and payer-specific requirements.

Monitor claim status and process secondary or tertiary claims asrequired.

Perform comprehensive AR collections , including tracking outstanding balances and resolving unpaid or underpaid claims.

Research and resolve claim errors, coding issues, and payer-specific infusion policies.

Manage prior authorization follow-up with the PA team and ensure claims are billed compliant with authorization terms.

Communicate with payers to resolve rejections, eligibility discrepancies, and coverage issues.

Denials, Appeals & Reconsiderations

Review, analyze, and resolve claim denials related to medical necessity, coding, benefit coverage, or documentation.

Prepare andsubmitappeal packets including clinical justifications, medical records, infusion notes, and prior authorization details.

Draft high-quality appeal letters based on denial category and payer requirements.

Track appeal turnaround times and follow up with payers until resolution.

Coordinate with prescribers to obtain clinical notes, labs, andadditionaldocumentsrequiredforapprovalsor appeals.

Complete credentialing and enrollment for providers with Medicare, Medi-Cal, and commercial insurance plans.

Maintain and update CAQH , NPPES , PECOS , and payer portal information.

Initiate and manage re-credentialing processes and track expiring documents.

Maintain an organized,compliantcredentialing database.

Communicate with insurers and internal teams to ensuretimelyactivation of provider billing privileges.

Division team/specific Accountabilities:

Communicate with patients to gather information required forbenefitsverification, billing setup, financial counseling, and to ensureaccurateprocessing of infusion orders and authorizations. Build clear, supportive communication that promotes trust and patient loyalty.

Investigate and verify medical benefits for infusion and specialty biologic services, including deductible, co-pay, out-of-pocket costs, prior authorization requirements, site-of-care restrictions, step therapy, and medical policy guidelines.

Coordinate with manufacturer financialassistanceprograms , copay foundations, and internal support teams to help eligible patients obtain financial support, copay cards, or patient-assistance funding whenappropriate.

Work closely with the Prior Authorization team by providing allrequiredclinical and documentation updates, ensuringtimelysubmission, tracking authorization progress, andmaintainingconsistent communication with the patient and provider.

Facilitate denial and appeal processes by requesting denial documentation, gathering clinical records, and preparing appeal packets. Compose appeal letters based on denialreason, medical necessity, and the patient’s clinical condition.

Conduct regular status checks with insurance companies on pending authorizations, appeals, and claim adjudications. Obtain approval information, document outcomes, and update copay or financialassistancestatuses whenrequired.

Identify, track