Credentialing and Denials Specialist

Company & Position Summary:       

Critical Care, Pulmonary and Sleep Associates is a multispecialty private physician practice, providing Critical Care, Pulmonary and Sleep medical services to the Denver metro area for over 40 years. Our dedicated team of Board-Certified Critical Care, Pulmonary and Sleep Physicians along with our skilled clinical and administrative staff exclusively serve nine Common Spirit and AdventHealth Hospital ICU’s and multiple outpatient clinic locations spanning Colorado’s front range. CCPSA’s organizational culture exemplifies excellence in patient centered care, unified teamwork, and a highly collaborative approach in all business and clinical operations. We are currently seeking a Credentialing and Denials Specialist to join our committed team of professionals.

The Credentialing and Denials Specialist is responsible for provider credentialing across commercial insurance payers, government programs, hospitals, and other healthcare organizations while serving as the primary resource for insurance claim denial resolution. This position ensures providers are appropriately credentialed, enrolled, appointed, and privileged to support timely reimbursement and uninterrupted patient care while researching, appealing, and resolving denied claims. The individual in this role partners with internal teams and insurance carriers to identify reimbursement trends, improve revenue cycle performance, maintain regulatory compliance, and support the organization's financial health. This role requires a commitment to the CCPSA culture of collaboration while identifying opportunities for continuous improvement and supporting the organization's shared values.

Essential Responsibilities and Tasks:

Provider Credentialing, Enrollment & Privileging

• Ensure CCPSA providers are credentialed, enrolled, appointed, and privileged with commercial and government payers, hospitals, and other healthcare organizations to support uninterrupted clinical operations and timely reimbursement.
• Complete provider enrollment, credentialing, recredentialing, revalidation, appointment, privileging, and ongoing maintenance activities with commercial and government payers, hospitals, and other healthcare organizations.
• Coordinate provider onboarding activities related to credentialing and privileging, including hospital application requirements and other required pre-start activities, as applicable.
• Maintain provider credentialing records and monitor compliance with licenses, certifications, DEA registrations, malpractice coverage, continuing education, and other credentialing requirements.
• Maintain accurate provider information within credentialing systems, payer portals, hospital credentialing systems, CAQH, and other required databases.
• Ensure all credentialing files meet standards set by the NCQA, TJC, CMS, hospitals, and payer-specific guidelines.
• Serve as the primary point of contact for provider credentialing, enrollment, appointment, and privileging questions.

Denials Management

• Review assigned denial work queues and investigate denied claims for accurate and timely resolution.
• Research and appeal insurance claim denials through review of coding, medical records, payer contracts, reimbursement guidelines, and applicable documentation.
• Maintain advanced knowledge of payer websites, reimbursement guidelines, and appeal processes for commercial and government payers, including Medicare, Medicaid, Medicare Advantage, Tricare, VA, and other payer plans.
• Analyze denial trends and identify root causes to proactively reduce future denials.
• Escalate denial issues and communicate recurring trends or payer policy changes to leadership.
• Ensure appeals are submitted within payer filing deadlines.

Revenue Cycle Support

• Stay current on payer policies, reimbursement regulations, and credentialing requirements.
• Assist with educating team members regarding payer updates, denial trends, and process improvements.
• Accurately document denial investigations, appeals, credentialing activities, and resolutions within appropriate systems.
• Collaborate with providers, payers, coding, billing, and other internal teams to resolve reimbursement issues and support efficient revenue cycle operations.
• Participate in quality improvement initiatives and projects that enhance revenue cycle performance.
• Perform other duties as assigned by the manager.

Skills, Education and/or Work Experience Requirements:

• Minimum of two (2) years of experience in provider credentialing, payer enrollment, medical billing, denial management, or revenue cycle operations. Hospital credentialing and privileging experience preferred.
• Demonstrated experience researching, appealing, and resolving insurance claim denials.
• Working knowledge of medical terminology, provider taxonomy, commercial and government payer guidelines, credentialing requirements, and healthcare reimbursement methodologies.
• Knowledge of hospital credentialing and privileging processes preferred.
• Excellent analytical, organizational, problem-solving, and critical thinking skills.
• Demonstrated commitment to exceptional customer service through professional communication, responsiveness, and timely follow-up.
• Ability to work independently while effectively managing multiple competing priorities and consistently meeting deadlines.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Outlook, Word, Excel, internet research, and payer portals.
• Experience with EPIC Resolute Professional Billing strongly preferred.
• High School Diploma or GED required.

Compensation:

• Competitive hourly compensation.
• Benefits effective date-of-hire (no waiting period).
• Comprehensive medical benefits. Company covers 80-85% percent of individual or family premium.
• Dental and vision benefits offered at no cost to the employee. Company covers 100% of individual or family premium.
• Life and AD&D benefits.
• Optional additional life & disability insurance at group discounts.
• PTO and holiday pay.
• 401k benefits with company contribution after eligibility period.
• Position reports to RCM Manager.