Provider Credentialing Specialist

Full-time Description

Job Summary

• In-person position only. Not remote. Note hybrid. Some travel may be requested at IEP's discretion and will be paid for/reimbursed. Candidates living within a practical commute of Farmington Hills, MI will be considered.*
  
  

This is a brand new position offering the incumbent a great opportunity for growth!

The Credentialing Specialist plays a critical role in supporting the Revenue Cycle Management (RCM) team by assisting with billing, coding, collections, and documentation. This role includes managing the hospital and billing credentialing process for new hires, ensuring that all necessary credentialing and licensing documents are submitted, verified, and processed accurately. The Credentialing Specialist ensures that new providers are properly credentialed and compliant with hospital and billing policies and regulatory requirements, facilitating smooth onboarding and uninterrupted claims processing.

Key Responsibilities

• Credentialing for New Hires:
• Coordinate the credentialing process for new hires, ensuring that all required documentation (e.g., licensure, board certifications, malpractice insurance, background checks) is collected, verified, and submitted to the appropriate hospital and payer organizations.
• Ensure that new providers meet all hospital credentialing requirements and that their credentials are entered into the system for billing and claims purposes.
• Monitor the progress of credentialing applications and work with the appropriate departments to resolve any issues or delays.
• Communicate with new providers to ensure timely submission of required documentation and inform them about the credentialing process.
• Track and ensure that all credentialing approvals are obtained before a provider begins patient care or submits claims.
• Maintain accurate records of credentialing status for each new hire and communicate with HR and other departments to ensure smooth onboarding.
• CAQH Portal Upkeep & Provider Communication:
• Assist in maintaining and updating provider information in the CAQH (Council for Affordable Quality Healthcare) portal to ensure that all credentials, documents, and profiles are complete and current.
• Follow up on pending provider credentialing and re-credentialing to ensure there are no delays in claims processing.
• PECOS Enrollment & Monitoring:
• Begin the enrollment process for new providers in the PECOS (Provider Enrollment, Chain, and Ownership System) by gathering necessary documentation and initiating connections in the system.
• Monitor the progress of PECOS connections, ensuring that providers are successfully enrolled or re-enrolled with Medicare and other relevant payers.
• RAI (Request for Additional Information) Monitoring & Tracking: Track the completion of RAI assessments, ensuring they are accurately documented and submitted within regulatory timelines.
• CNR (Chart not Received):
  

Monitor and address CNR instances across all sites and service lines.

• Timely Completion of Department Chair Requests: Assist in responding to requests from Department Chairs by preparing data, reports, and other documentation as needed, ensuring tasks are completed efficiently and within deadlines.
• Denial Management: Track and manage denied claims, identifying the root causes and collaborating with the team to resolve issues
• Internal Daily/Monthly/Annual Visit Composition, Tracking, and Reconciliation:
• Composition: Prepare and maintain accurate daily, monthly, and annual records of administrative tasks, visits, and services rendered across all service lines.
• Tracking: Monitor and track the flow of patient visits, ensuring that all relevant administrative data is captured accurately across departments and service lines.
• Reconciliation: Perform reconciliations of visit data against billing information to ensure consistency, accuracy, and completeness. Identify and resolve any discrepancies between internal records and billing systems.
• Communication with Billing Companies Regarding Discrepancies:
• Identify discrepancies between internal records (such as visits and services) and what has been reported by billing companies.
• Collaborate with billing companies to investigate and resolve any discrepancies, ensuring that data is aligned and all services are billed accurately.
• Work closely with external billing teams to ensure that the correct codes, charges, and service line information are reflected in the billing submissions.
• Team Collaboration: Work with various departments, including clinical staff, finance, human resources, and insurance providers, to ensure the smooth flow of the revenue cycle process and resolve any billing-related issues.
  

As Needed: Support additional tasks or projects assigned by management or other departments, such as data analysis or preparation for special audits.

Requirements

Skills and Qualifications:

• High school diploma or equivalent required; Bachelors degree in healthcare administration, business, human resources, or related field preferred.
• Previous experience in healthcare administration, medical billing, or a related field strongly preferred.
• Familiarity with hospital credentialing processes for new hires, including document verification, licensure checks, and payer-specific requirements.
• Proficiency in revenue cycle management software and Microsoft Office Suite (Excel, Word, PowerPoint).
• Knowledge of healthcare billing codes (CPT, ICD-10, HCPCS) and insurance claims processes.
• Strong attention to detail and the ability to perform complex reconciliations and data tracking across multiple service lines.
• Strong organizational skills and the ability to manage multiple tasks and meet deadlines.
• Excellent communication skills, both verbal and written, to effectively communicate with providers, insurance companies, and internal teams.
• Ability to maintain confidentiality and comply with HIPAA guidelines.
• Strong problem-solving skills and the ability to manage sensitive or complex issues with professionalism.
• Previous experience in navigating Electronic Health Record software (Cerner & EPIC) preferred.
  
  

Working Conditions

• This position typically works in an office or healthcare setting with regular business hours of 8:30 AM - 5 PM, Mon - Fri.
• Availability may be required during peak periods, such as end-of-month or end-of-year reporting, or to address urgent issues related to credentialing or onboarding.
  
  

Salary Description $50,000s