Credentialing Specialist

Company DescriptionAt BilliMD, we specialize in simplifying medical billing and revenue cycle management. Our end-to-end solutions integrate seamlessly with EHR/EMR systems, freeing your staff from manual tasks and allowing them to focus on patient care. We have a team of certified coders, seasoned professionals, and healthcare experts who are dedicated to ensuring efficiency and precision in revenue cycle management, medical coding, and credentialing. Our commitment to operational excellence includes diligent claim monitoring, error minimization, and transparent financial performance analysis to help maximize your revenue.

Role DescriptionThis is a full-time on-site role as a Credentialing Specialist located in Miami, FL. As a Credentialing Specialist at BilliMD, you will be responsible for managing credentials, renewals, and providing maintenance and support. You will also be involved in coding and medical billing, including knowledge of the latest updates to ICD-10, CPT, HCPCS, and DRG codes, compliance with NCQA HEDIS, analysis and benchmarking for E&M coding levels, and efficient management of patient information. Additionally, you will play a key role in denial management, re-verifying patient eligibility, managing the revenue cycle, identifying opportunities, and reviewing and preventing potential coding errors. You will also be responsible for accounts receivable, including claim submission, payment generation, denial management, and clearing of old receivables.

Key Responsibilities:Provider Credentialing and Re-credentialing:Initiate and oversee the credentialing and re-credentialing process for all healthcare providers.Collect, review, and verify all necessary documentation, including but not limited to medical licenses, board certifications, malpractice insurance, and professional references.Conduct thorough background checks, including criminal background checks, Office of Inspector General (OIG) checks, and checks against the National Practitioner Data Bank (NPDB).Documentation and Database Management:Maintain up-to-date records of all credentialing documents in a secure and confidential manner.Ensure accurate and timely entry of provider information into credentialing databases and systems.Regularly update and audit provider files to ensure compliance with changing regulations and organizational policies.Compliance and Quality Assurance:Stay informed about relevant healthcare regulations, accreditation standards, and best practices in credentialing.Work closely with legal and compliance departments to ensure all credentialing activities meet state, federal, and accrediting body standards.Prepare and present credentialing files for review by credentialing committees or boards.Provider Communication and Support:Serve as the primary point of contact for healthcare providers throughout the credentialing process.Provide guidance and assistance to providers in completing required documentation and resolving any issues or discrepancies.Communicate effectively with providers regarding the status of their credentialing or re-credentialing applications.Interdepartmental Collaboration:Collaborate with human resources, medical affairs, and department heads to coordinate provider onboarding and ensure a smooth transition for newly credentialed providers.Work with insurance and billing departments to resolve any credentialing-related issues affecting provider billing or insurance panel status.

Required Skills and Qualifications:Bachelor’s degree in healthcare administration, business administration, or a related field.Minimum of 3 years of experience in credentialing, medical staff services, or a related field within a healthcare setting.In-depth knowledge of healthcare regulations, credentialing standards, and compliance requirements.Proficiency in credentialing software and databases.Strong organizational skills and attention to detail.Excellent communication and interpersonal skills.Ability to work independently and manage multiple tasks simultaneously.

Excellent understanding of all the steps involved in the credentialing process:Preparation:Identify providers requiring credentialing or re-credentialing.Notify providers and request necessary documentation.Collection and Verification:Collect all required documents from providers.Verify the authenticity and validity of documents through direct contact with issuing institutions or via primary source verification methods.Assessment and Evaluation:Evaluate provider qualifications and compliance with organizational and regulatory standards.Address any discrepancies or issues with provider documentation.Credentialing Committee Review:Prepare and present provider files to the credentialing committee or board for approval.Communicate committee decisions to providers and relevant departments.Ongoing Monitoring and Compliance:Monitor expiring credentials and initiate re-credentialing as necessary.Stay updated on changes in credentialing requirements and adjust processes accordingly.