Under the general supervision of the Director of Clinical Services, the Credentialing Specialist is responsible for the overall revenue cycle and medical credentialing management of the counseling program. This includes compiling, analyzing, and summarizing the revenue budget and medical credentialing management for the program. Responsible for managing program fiscal functions such as accounts payable and receivable and for coordinating payment processes with vendors and accounting staff. Prepares and publishes monthly ad-hoc budget and statistical reports.
Essential Job Functions:
- Establish and maintain all provider credentialing and credentialing of the group and its performing providers for our current contracts, new providers, and new practice locations and expansions.
- Responsible for the accuracy and integrity of the credentialing files, provider data management, monitors external credential databases such as CAQH, Availity, NPI and TMHP enrollments, and individual health plan portals like Superior, to ensure data is updated and ready for quick retrieval and use by interested health plans.
- Meet federal requirements for quarterly Provider Directory updates/attestations.
- ERA/EFT Enrollment
- Provides ongoing revenue cycle management to strengthen revenue while complying with regulatory requirements:
- Coordinate with the intake process to ensure verification and authorization.
- Charge Capture and entry.
- Identify and resolve problems related to front-end scheduling and coding.
- Oversee claim scrubbing, submission, and claim status inquiry.
- Remittance Advice
- Payment posting, adjustments, patient billing, and export.
- Denials and appeals
- Use payor-specific contract terms to resolve payment variances.
- Identify and report trends with contracts and current practice limitations to optimize reimbursements, such as the Medicare waiver and incident-to billing.
Minimum Requirements:
- High School diploma or equivalent and 3 years in the medical insurance field are required. A Bachelor of Science degree in business, accounting or medical field is preferred.
- Knowledge of TX Medicaid program, including the Managed Care Organizations and service areas.
- Experience in medical revenue cycle management end to end.
- Knowledge of medical terminology.
- Experience with behavioral health and CPT coding.
- Thorough knowledge of insurance contracts.
- Working knowledge of Excel.
- Ability to analyze problems, develop solutions, and implement new procedures.
- Strong verbal and written communication skills.