This is a remote position.
We are seeking a highly skilled and detail-oriented Medical Insurance Credentialing Specialist with proven experience working with multiple payers, including commercial insurance carriers, Medicare, Medicaid, and managed care organizations. The ideal candidate will be responsible for managing the full lifecycle of provider credentialing, re-credentialing, and medical billing processes. This includes preparing, submitting, and following up on claims, ensuring timely and accurate reimbursement, and maintaining compliance with payer-specific requirements and federal and state regulations.
Key Responsibilities
Credentialing & Enrollment:
- Prepare and submit credentialing applications for new providers to a variety of insurance payers.
- Complete re-credentialing processes according to payer timelines to avoid network participation lapses.
- Maintain accurate and up-to-date provider records in credentialing databases and payer portals.
- Coordinate with providers to obtain necessary documentation, certifications, licenses, and signatures.
Billing & Claims Management:
- Accurately review, prepare, and submit medical insurance claims for a variety of payers using electronic health record (EHR) and billing systems.
- Ensure proper coding using CPT, HCPCS, ICD-10, and modifier guidelines.
- Validate patient demographics, insurance eligibility, and coverage details before claim submission.
- Apply knowledge of different payer rules, fee schedules, and claim filing limits.
- Navigate multiple payer portals for claim status, adjustments, and appeals.
- Manage claim edits and rejections based on payer-specific requirements.
- Post payments, contractual adjustments, and write-offs accurately.
- Identify and address underpayments and payment discrepancies.
- Reconcile daily, weekly, and monthly payment reports to ensure accuracy.
- Research and analyze claim denials and rejections.
- Prepare and submit timely appeals with appropriate documentation.
- Maintain follow-up logs to track outstanding claims until resolved.
- Adhere to HIPAA, CMS, and payer compliance guidelines.
- Maintain accurate and complete billing records in accordance with office policies.
- Stay updated on insurance and coding changes through continuing education.
- Work closely with clinical, administrative, and revenue cycle staff to resolve billing issues.
- Communicate professionally with insurance representatives, patients, and colleagues.
- Provide feedback to management regarding recurring payer issues or process improvements.
Payer Relations & Compliance:
- Serve as the liaison between providers and insurance payers during the credentialing process.
- Monitor and interpret payer requirements, policies, and updates to ensure compliance.
- Resolve issues and discrepancies related to credentialing, enrollment, and network participation.
- Ensure credentialing practices meet all regulatory standards, including NCQA, CMS, and HIPAA.
Documentation & Tracking:
- Maintain credentialing logs, spreadsheets, and databases to track application status, expiration dates, and deadlines.
- Audit credentialing files to ensure completeness and accuracy.
- Prepare reports for management on credentialing activities, pending applications, and compliance status.
Requirements
Qualifications
Education & Experience:
- High school diploma or equivalent required; associate or bachelor’s degree in healthcare administration, business, or related field preferred. Certification in medical billing/coding (CPB, CPC, or equivalent) is a plus.
- Minimum 2 years of experience in medical credentialing and/or billing, preferably across multiple payers.
- Strong working knowledge of CAQH ProView, NPPES, PECOS, Availity, payer portals, and EHR/billing software.
- Proven track record of accurate claim submission, denial resolution, and maintaining compliance with payer requirements.
Skills & Competencies:
- Excellent attention to detail and accuracy.
- Strong organizational, time-management, and problem-solving skills.
- Effective communication skills, both written and verbal.
- Ability to manage multiple projects and deadlines simultaneously.
- Proficiency in credentialing/billing software.
- Strong understanding of CPT, ICD-10, and HCPCS coding.
Work Environment & Conditions
- This role is remote.
- Standard business hours, Monday–Friday.
- Requires sitting for extended periods and extensive use of computer systems.
Performance Metrics
- Timeliness of credentialing, re-credentialing, and claim submissions.
- Accuracy of credentialing files, claims, and documentation.
- Successful provider enrollment and claim reimbursement with minimal delays or denials.
- Compliance with payer and regulatory requirements.
— Sarah J.
·
Marketing Manager
★★★★★
Verified
