To provide services to ensure efficient, timely and accurate insurance credentialing and re-credentialing of all healthcare providers. Under the supervision of the Director, the Credentialing Coordinator will be responsible for ensuring that all providers have current insurance credentialing. The Billing Credentialing Specialist is responsible for all aspects of billing Medical, Dental and Optometry claims in a FQHC setting. The Billing Credentialing Specialist, a key position in the Revenue Cycle, facilitates the claims process, including accurate and timely claim creation, follow-up and correspondence with providers, insurance inquiries and patients. The incumbent will assist in the clarification and development of process improvements and inquiries to maximize revenues.
Work is typically performed in an office environment, with participation in customer/community services activities as needed. Accountable for satisfying all job specific obligations and complying with all organization policies and procedures. The specific statements for this job description are not intended to be all inclusive. They represent typical elements considered necessary to successfully perform the job.
This position requires the ability to handle confidential matters with a high level of discretion, process all aspects of insurance credentialing with a high degree of accuracy; meet processing deadlines, use basic math accurately; prepare reports; learn policies and procedures; organize work efficiently, using sound independent judgment; think independently and analytically; use a variety of standard office and computer equipment; communicate effectively and respectfully with a diverse group of people, agents, government community agency representatives, and the public.
Knowledge, Skills, and Abilities
- Responsible for timeliness of provider enrollment with necessary payors.
- Create and maintain accurate records of all enrollments
- Prepares and submits clean claims to third party payers either electronically or by paper.
- Follows billing guidelines and legal requirements to ensure compliance with federal and state regulations.
- Respond to account inquiries from patients, payers, providers, and/or other staff as requested.
- Identifies and resolves patient/insurance billing issues.
- Work closely with team members regarding claim appeals, denials, resolution, and education.
- Performs and monitors all steps in the billing processes to ensure maximum reimbursement from patients, government, and commercial payers as well as from special billing arrangements.
- Understands Medicare, Medicaid and other commercial payer rules and regulations applicable to billing. Updates business office staff, clinics, residents, and faculty of changes as appropriate.
- Responsible for ensuring all providers are oriented to coding, billing, and documentation compliance.
- Responsible for the continuing coding, billing, and documentation education for all providers and residents.
- Understands the considerations of coding in Value Based payment contracts.
- Responsible for reviewing and implementing changes from payer bulletins.
- Use online healthcare databases and other resources for verification and claim status.
- Deliver the highest quality service to internal and external customers.
- Assist other members of the team with projects as needed.
- Maintains strictest confidentiality; adheres to all HIPAA guidelines/regulations.
- Other duties as assigned by management.
Qualifications/Education Requirements
High school diploma or GED certificate required. 2 years’ experience in physician credentialing and provider enrollment. 2 years in FQHC billing or 5 or more years in physician or hospital billing of accounts receivable. Experience in medical billing/coding preferred. Excellent computer skills and a familiarity with ADA, CPT, and ICD-10 coding is required. Certified Professional coder (CPC) certification desired.
Core Competencies
- Competent in both oral and written English.
- Read and interpret policies and procedures.
- Processes and posts accounts receivable payments to patient accounts.
- Posts insurance payments and adjustments for medical, dental, behavioral health, and optometry claims accurately and on schedule.
- Reconciles transaction activity.
- Reviews private insurance claims for accuracy prior to submission to payers for payment.
- Processes claims to payers in a timely manner.
- Works denied claims by correcting and resubmitting claims to payers in a timely manner.
- Assists with provider and location credentialing.
- Provides technical and billing assistance to clinic staff as needed.
- Communicates with staff, patients, and intermediaries.
- Assists HIT Trainers with electronic practice management and billing requests.
- Performs other duties as requested or required.
- Competent in basic computer skills, including spreadsheets and business letters.
- Competent in basic math, including calculation of ratios and percentages.
- Upholds, complies with, and enforces the Core Principles and Code of Conduct
