Credentialing and Enrollment Specialist
On-siteWilmington, North Carolina, United States
Job Summary
Review and authenticate credentials, licenses, and certifications for providers while enrolling facilities and providers with contracted payors. Oversee credentialing, recredentialing, and enrollment information within Federal and State guidelines using credentialing software, including onboarding new providers by creating files and initiating communication. Prepare and submit clean UB and 1500 claims to third-party payers, responding to inquiries from patients, providers, and insurance companies to resolve billing issues and maximize reimbursements. Maintain accurate databases for CAQH, NC Tracks, Medicare, and commercial insurance, tracking license expirations and renewals in a timely manner. Work with the team to resolve claims issues regarding credentialing and enrollment, ensuring correct reimbursement of all affected claims.
Required Qualifications
- High School Diploma/GED
- Minimum 2 years in healthcare revenue cycle functions experience
- Maintain a strong and working knowledge of credentialing and enrollment rules, regulations, and processes
- Experience with payor enrollment for facilities, LICP, and OLICP
- Knowledge of Credentialing/Enrollment Software
- Accurate and precise attention to detail
- Excellent verbal and written communication skills
- Must be focused, self-directed, organized, and strong problem-solving abilities
- ICD-10, CPT/HCPCS codes, medical terminology, and billing processes
- Knowledge of Medical Billing/EHR (Electronic Health Records)
- Knowledge of EOBs, EFTs and ERAs
- Knowledge of Microsoft Office software
- Able to work both independently and as part of a team
- Must be able to lift and/or move up to 20 pounds
- Close vision (clear vision at 20 inches or less)
- Color vision (ability to identify and distinguish colors)
Desired Qualifications
- Preferred 1 year credentialing/enrollment experience
- Special consideration will be given to those who have a certificate from: NAMSS: Certified Professional Enrollment Specialist (CPES) or Certified Professional Credentialing Specialist CPCS)
- Special consideration will be given to those who have a certificate from: Decision Health: Provider Enrollment Specialist Certificate (PESC)
- Special consideration will be given to those who have a certificate from: AAPC: Credentialing Specialist
- Special consideration will be given to those who have a certificate from: ArchPro: Community Health Credentialing Specialist (CH-CS)
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