Credentialing Specialist

Job Summary

The role of the Credentialing Specialist is to maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases, and complete re-credentialing applications for commercial payers, as necessary.

​​Role and Responsibilities​

• Completes all data entry for forms necessary to initiate provider credentialing.
• Collects required documents needed for insurance companies based on provider type to complete credentialing.
• Document and review required updates from insurance companies regarding rates.
• Reviews and resolves credentialing issues that are not valid and contacts insurance carriers to verify/validate requirements to ensure accuracy and avoid potential denial.
• Validates all necessary licenses and codes to ensure they are valid for scheduled services.
• Provides timely updates to each provider’s CAQH database file according to the schedule published by CMS.
• Maintains accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases.
• Completes re-credentialing applications for commercial payers, as necessary.
• Verifies patient-specific benefits and precisely documents specifics for various payer plans including patient coverage, cost share, and access/provider options.
• Ensures all account activity is documented in the appropriate systems and shared with all appropriate staff timely and thoroughly.
• Identifies and forwards potential reimbursement problems to the billing team.
• Collaborates with other team members to support correct reimbursement.
• Works cohesively with billing and collections team to address reimbursement issues.
• Completes ad hoc work, as needed.
• Refers complex issues to the supervisor for review and/or action.
• Maintains strict confidentiality on all client records and business-related records, as required under HIPAA guidelines.
• Follows regulatory requirements.
• Reviews claim rejections resulting from provider credentialing.
• Participates in staff development and training, including staff meetings, in-service trainings and annual trainings required by Sanford Behavioral Health on a timely basis.
• Adheres to established Code of Ethics, Standards of Practice, and employee handbook.
• Possess a positive attitude to enhance a cooperative and energetic work environment.
• Performs other duties as assigned.

​​Qualifications and Education Requirements​

• Two (2) to four (4) years of insurance verification and credentialing experience, preferred.
• Requires minimum of two (2) years’ experience in customer service, medical billing and coding, benefits verification, healthcare, business administration or similar vocation.
• An equivalent combination of education and experience will be considered

Knowledge/Skills/abilities

• Professional experience performing insurance verification or billing services.
• Knowledge of different types of behavioral health and medical insurance coverage and policies. Strong customer service experience, interpersonal skills, and professionalism.
• Proficient with MS Word and Excel including fundamentals of data entry/typing.
• Independent problem solver and ability to make good decisions.
• Strong attention to detail, flexibility, and the ability to adapt to changing work situations.
• Effective written and verbal communication.
• Basic level mathematical proficiency, with a strong ability to understand, interpret, calculate, and communicate financial responsibility.
• Knowledge of In Network and Out of Network processing.
• The ability to meet critical deadlines.
• Sound judgment and strong skills with respect to interpersonal relations, critical thinking, problem solving and analysis.
• Must possess positive attitude to enhance a cooperative and energetic work environment.
• Refer complex issues to the supervisor for review and or action.
• Working knowledge of behavioral health and medical terminology and CPT and ICD10 Coding.
• Familiar with insurance billing policies and procedures.
• Time management skills: must maintain an ability to focus and work efficiently as insurance paperwork commonly needs to be processed in a timely manner.
• Ability to work within a team setting and create an environment where all are valued and work together cohesively.
• Knowledge of office administration procedures with the ability to operate most standard office equipment.
• Excellent communication skills, both written and verbal.
• Self-motivated with initiative.
• Demonstrates professional behavior reflective of Sanford’s Mission Statement, Philosophy, and Values. Must be able to relate well to all kinds of people both inside and outside the organization; builds appropriate rapport; builds constructive and effective relationships; uses diplomacy and tact.

Physical Requirements

• Prolonged periods of sitting at a desk and working on a computer.
• Must be able to lift 15 pounds.
• Must be able to perform repetitive tasks such as typing for extended periods of time.
• Must be able to clearly express and exchange ideas by means of spoken words to impart oral information to employees or others accurately or quickly, engaging in sometimes lengthy conversations or presentations.
• Must be able to ascend and descend stairs daily.
• Must be able to seize, hold, grasp, turn or otherwise work with your hand or hands.
• Must be able to perceive sound by ear to interpret oral information from employees or others accurately or quickly.
• Work will be performed in an office environment with fluctuating temperatures.

ADA Disclaimer

The employee must be able to perform the essential functions of the position adequately. If requested, reasonable accommodations will be made to enable employees with disabilities to perform the essential functions of their job, absent undue hardship. All requests must be made to the Human Resource Department in writing.