Billing and Credentialing Specialist

Profile Summary:

The Billing & Credentialing Specialist is responsible for managing the full revenue cycle for infusion services, including benefits investigation, verification, accurate claim 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 and timely activation. The position supports patients, providers, and internal departments to optimize reimbursement and maintain continuity 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, and submit claims 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)

• Modifier accuracy (JW, JG, 59, 25, etc.)

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

• Monitor claim status and process secondary or tertiary claims as required.

• 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 and submit appeal 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, and additional documents required for approvals or appeals.

Provider Credentialing & Payer Enrollments

• 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, compliant credentialing database.

• Communicate with insurers and internal teams to ensure timely activation of provider billing privileges.

Division team/specific Accountabilities:

• Communicate with patients to gather information required for benefits verification, billing setup, financial counseling, and to ensure accurate processing 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 financial assistance programs, copay foundations, and internal support teams to help eligible patients obtain financial support, copay cards, or patient-assistance funding when appropriate.

• Work closely with the Prior Authorization team by providing all required clinical and documentation updates, ensuring timely submission, tracking authorization progress, and maintaining consistent 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 denial reason, 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 financial assistance statuses when required.

• Identify, track, and escalate service-delaying issues related to prior authorizations, benefit determinations, clinical documentation, or financial assistance gaps to ensure uninterrupted patient therapy and timely infusion scheduling.

• Build and maintain effective working relationships with prescriber offices, referral partners, and clinical staff treating assigned disease states. Provide ongoing updates regarding case status, authorizations, and payer requirements.

• Complete all required assessments or checklists mandated by manufacturer programs, payer requirements, or internal workflow processes to ensure compliance with program standards.

• Review and respond to notifications of patients who require financial assistance, providing them with available program options, community resources, and support to help minimize out-of-pocket burden.

• Assist patients with submitting financial assistance applications, including obtaining consent forms, uploading documentation, completing electronic applications, and following up with financial assistance programs to prevent therapy interruptions.

• Maintain timely updates on pending or unfilled infusion orders, keeping prescription and authorization statuses current in the system at least every 48 hours or per department protocol.

• Ensure that all activities comply with organizational standards, payer guidelines, manufacturer program requirements, and HIPAA. Deliver service in a manner that meets the highest standards of quality, accuracy, and patient care.

Experience:

• A minimum of 2 years of prior experience in a medical records department or like setting preferred.

• Prior experience with an Infusion clinic. (preferred)

• Dealing with third party billers. (preferred)

Behavioral Competencies:

• Excellent verbal and written communication skills.

• Excellent interpersonal, negotiation, and conflict resolution skills.

• Excellent organizational skills and attention to detail.

• Strong analytical and problem-solving skills.

• Ability to prioritize tasks and to delegate them when appropriate.

• Ability to act with integrity, professionalism, and confidentiality.