Credentialing and Billing Specialist

4 weeks ago

Laurel, United States DiscoverU Health Full time

Hiring now. Part-time role - Maryland (Remote)

Must have previous credentialing experience.

Must have previous billing experience.

This role will credential practitioners ( various specialties) for network participation with CareFirst BlueCross BlueShield, Aetna, United Health, Cigna, Optum, Humana - TriCare and other payers. Must accurately organize and maintain all provider data while ensuring compliance with regulatory, accreditation, legal and company requirements and standards

**Credentialing ESSENTIAL FUNCTIONS**:

- Respond to more complex external and internal inquiries regarding provider participation eligibility and criteria, provider data detail/structure, participation status, credentialing, contractual status and provider file updates.
- Direct focus on the provider experience, providing timely resolution dependable follow-up and proactive measures to ensure successful credentialing is achieved.
- Professional etiquette, communication and sound decision-making are required.
- Once verified, accepted and approved, determines the appropriate networks for participation and obtains the appropriate executed contracts to effectuate the professional relationship and structures the provider group accordingly.
- Maintains the provider file, the provider information inventory workflow system and electronic provider files with updated provider information during processes, such as credentialing, re-credentialing, demographic updates, terminations and all other provider file maintenance activities.
- Processes provider file inputs in accordance with applicable state laws and departmental guidelines. Verification of provider data and system release entered the provider file database, ensuring successful integration with the other corporate systems.
- Prepares written responses to obtain incomplete or missing information and or communicates effectively telephonically.

**Billing ESSENTIAL FUNCTIONS**:

- Performs accounts receivable follow-up/collection procedures to obtain timely reimbursement from third-party carriers and other payment sources on insurance invoice balances
- Performs collection activity for assigned divisions, third-party carriers and individual providers
- Maintains contacts with third-party carriers and communicates billing/reimbursement changes to management in a timely manner
- Assists in the evaluation of accounts receivable and participates in the development of collection strategies to decrease outstanding balances
- Assists in maintaining the integrity of the accounts receivable system database by reviewing data input for completeness and accuracy - including updating account information and transferring charges to the correct financial class
- Ensure all funds are accurately and timely resolve all outstanding claims for effective revenue cycle management
- Contact insurance carriers directly to confirm receipt of the claim(s) and follow appeal procedures for denied claims and reimbursement below the contractual fee schedule
- Identifies patient/third party carrier complaints, resolves and communicates these complaints to management
- In accordance with operational policies and procedures, makes adjustments to patient accounts as necessary to facilitate timely reimbursement
- Contributes to the achievement of established department goals and objectives and adheres to department policies, procedures, quality standards and safety standard
- Participates in multidisciplinary quality and service improvement teams as appropriate
- Must be available for periodic meetings, training and/or other business-related activities."

**QUALIFICATIONS**:
**Education Level**: High School Diploma or GED required

**Experience**:

- 3 years of physician credentialing experience or health insurance / managed care operations experience in a customer service, claims, billing, and enrollment, or call center environment.
- 2 years of collection experience in medical billing operations.
- Experienced with eClinical Works EHR
- Knowledge of ICD9/10 and CPT4 coding as it relates to third-party carrier reimbursement
- Knowledge of federal, state and local legal and regulatory provisions that relate to collection activities Knowledge of third-party carrier operating procedures and practices
- particularly as they relate to levels and methods of reimbursement
- Proven skill in defining problems, collecting data, interpreting billing information
- Ability to examine documents for accuracy and completeness, to prepare records in accordance with detailed instructions
- Proficiency in the use of computer and calculator
- Effective verbal and written communication skills

**Preferred Qualifications**:

- Bachelor’s Degree in Business, Healthcare Administration, or related field

**Preferred Licenses / Certifications**:

- Certified Provider Credentialing Specialist (CPCS)
- Certified Professional Biller (CPB)

**Knowledge, Skills and Abilities (KSAs)**:

- Must be proficient in the use of Excel spreadsheets, a

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