The Billing and Credentialing Specialist is responsible for managing

and overseeing the coding, billing and physician credentialing processes along with

company credentialing with CMS and private insurance companies. This role involves

submitting and following up on claims, working with insurance companies, and ensuring

that all healthcare providers are properly credentialed and able to bill for services. The

ideal candidate will have a thorough understanding of healthcare billing in the Skilled

Nursing Facility market, codes for telehealth, procedures, insurance regulations, and

credentialing processes in the US healthcare system.ips: Provide a summary of the role, what success in the position looks like, and how this role fits into the organization overall.

Responsibilities

1. Billing and Claims Management:

• Prepare and submit billing data and medical claims to insurance

companies.

• Ensure the accuracy and completeness of all coding and billing

information.

• Follow up on unpaid claims and resolve billing issues.
• Manage the appeals process for denied claims.
• Maintain up-to-date records of billing activities.

2. Credentialing:

• Coordinate the credentialing process with outside vendor(s) for all

healthcare providers, ensuring timely and accurate completion.

• Maintain current knowledge of credentialing requirements for all providers.
• Maintain working knowledge of current coding schedules applicable to

virtual diagnostics

• Keep accurate records of credentialing information and ensure all

documents are up to date.

• Liaise with healthcare providers, insurance panels, and other entities as

required.

3. Medical Coding

• Assigning Codes: Reviewing medical records and assigning appropriate

alphanumeric codes to diagnoses, procedures, and services using

standard coding systems such as ICD-10-CM (International Classification

of Diseases, 10th Revision, Clinical Modification) for diagnoses and CPT

(Current Procedural Terminology) or HCPCS (Healthcare Common

Procedure Coding System) for procedures and services.

• Compliance: Ensuring coding compliance with regulatory requirements,

including those set by government agencies such as Centers for Medicare

& Medicaid Services (CMS) and private insurers. Adhering to official

coding guidelines and healthcare regulations to prevent fraudulent or

erroneous claims.

• Accuracy: Maintaining accuracy in code assignment to reflect the

patient's condition and the services provided. Ensuring that codes reflect

the physician's documentation accurately and completely.

Record Keeping: Keeping detailed records of code assignments and

maintaining patient confidentiality in accordance with HIPAA (Health

Insurance Portability and Accountability Act) regulations.

• Communication: Collaborating with healthcare providers, billing

specialists, and other staff to clarify documentation and resolve coding-

related issues. Effective communication is crucial for accurate coding and

billing processes.

• Audit Preparation: Assisting in internal and external coding audits to

ensure compliance with coding guidelines and accuracy of coded data.

Providing documentation and explanations as needed during audits.

• Continuous Education: Staying updated on changes in coding

guidelines, regulations, and healthcare industry practices through ongoing

education and training. Maintaining certification through continuing

education requirements.

• Revenue Cycle Management: Supporting revenue cycle management by

accurately translating medical services into codes for billing and

reimbursement purposes. Maximizing revenue by ensuring complete and

accurate documentation and coding.

• Quality Improvement: Identifying opportunities for process improvement

in coding workflows and documentation practices to enhance accuracy,

efficiency, and compliance.

• Ethical Conduct: Upholding professional and ethical standards in coding

practices, including integrity, honesty, and confidentiality.

4. Compliance and Regulations:

• Stay informed about current healthcare regulations, including HIPAA, and

ensure compliance.

• Understand and comply with insurance and healthcare regulations and

requirements.

• Ensure all billing and credentialing processes meet state and federal

standards.

5. Customer Service:

• Provide support and answer inquiries from patients, healthcare providers,

and insurance companies.

• Resolve any issues related to billing, insurance, or credentialing.

6. Reporting and Administration:

• Generate and analyze reports on billing activities, insurance

reimbursements, and credentialing status.

• Assist with audits and investigations related to billing and credentialing.

Qualifications

Certified Medical Coder with a minimum of 3-5 years’ experience

• Associate or bachelor’s degree in healthcare administration, finance, or related

field preferred.

• In-depth knowledge of medical billing procedures, insurance policies, and

credentialing processes.

• Familiarity with healthcare laws, regulations, and standards, including HIPAA.
• Excellent organizational skills and attention to detail.
• Strong communication and interpersonal skills.
• Proficiency in medical billing software and electronic medical records (EMR)

systems.