Billing Credentialing Specialist

Job Title: Billing Credentialing Specialist

Reports to: Manager of Billing and Collections (AR and Claims)

Summary:  The Billing Credentialing Specialist is responsible for reviewing, analyzing, and resolving professional billing claim edits and denials related to provider credentialing. This position researches claim issues, identifies root causes, coordinates necessary provider updates, and ensures timely resubmission of corrected or denied claims to maximize reimbursement and reduce recurring denials.

The Specialist works closely with Billing, Managed Care, Credentialing, and other internal departments to ensure provider information is accurate and current across payer, NPPES, and internal systems.

The ideal candidate is highly analytical, detail-oriented, organized, and proactive, with strong knowledge of professional medical billing, denial management, provider credentialing, and revenue cycle processes.

Essential Duties and Responsibilities:

• Review, analyze, and resolve professional billing claim edits and denials, identifying root causes and appropriate corrective actions.
• Collaborate with Managed Care, Credentialing, Billing, and other departments to research and resolve provider-related billing, enrollment, credentialing, and demographic issues.
• Research payer requirements and maintain accurate provider information using payer rosters, internal rosters, NPPES (National Plan and Provider Enumeration System), and applicable systems.
• Monitor provider updates and credentialing status through completion, including auditing applicable work queues and ensuring timely release of held charges in Epic.
• Manage assigned A/R and denial work queues, documenting accounts, prioritizing high-dollar, aging, and time-sensitive claims for timely follow-up and resolution.
• Resubmit applicable denied or corrected claims following completion of required provider or credentialing updates.
• Monitor denial trends and aging, escalate unresolved issues, and communicate pertinent findings to appropriate departments and management.
• Generate and maintain reports related to claim edits, denials, credentialing issues, and assigned performance metrics.
• Communicate pertinent provider credentialing, enrollment, and billing issues to the appropriate departments and management.
• Perform additional duties as assigned.

Knowledge, Skills & Abilities:

• Knowledge of collections, healthcare terminology and office procedures.
• Attention to detail with the ability to identify/resolve problems and document the outcome.
• Strong concise, clear written and verbal communication skills.

• Organizational skills – ability to multi-task and work independently.
• Solid, strong analytical and problem-solving skills.

• Goal-oriented – holds him/herself accountable to achieving shared and personal goals.
• Establish and maintain long-term customer relationships, building trust and respect by consistently meeting and exceeding expectations.
• Establish and maintain effective working relationships with employees, departments, and external vendors.
• Maintains a high level of confidentiality.
• Advanced skills with Microsoft Office applications: Word and Excel.
• Excellent time management and workload prioritization skills.

Education/Experience:

• Minimum three years’ experience in revenue cycle processes and denial management
• Ability to demonstrate problem solving, analytical, oral and written communication skills, and the ability to interact professionally with a diverse group
• Working knowledge of EPIC software desired.
• Exposure to provider enrollment or credentialing desired.
• Ability to engage in multiple initiatives simultaneously while working in a dynamic environment subject to impromptu changes in schedules and priorities
• Proficient in Microsoft Office applications, Outlook and Excel
• Strong initiative – establish goals and take responsibility for meeting them within defined timelines