Credentialing & Billing Specialist

Summary

The Credentialing & Billing Specialist is responsible for ensuring accurate and timely provider credentialing, payer enrollment, and revenue cycle support.  This role serves as a critical bridge between front-end operations and billing, helping prevent denials, improve compliance, and optimize reimbursement outcomes. Essential Duties & Responsibilities Credentialing & Payer Enrollment

Advise on end-to-end provider credentialing and payer enrollment processes, including initial applications, re-credentialing and ongoing maintenance Maintain and update provider information in PNM System, CAQH, PECOS and payer-specific portals Track credentialing and enrollment status, ensuring timely completion and preventing lapses in participation Serve as the primary point of contact with payers for enrollment status, issue resolution, and follow-up Maintain accurate records of provider credentials, licenses, certifications, and payer participation status.

Process Design & Optimization

Design, implement and continuously improve credentialing and enrollment workflows to increase efficiency and reduce delays Establish tracking systems and controls for re-credentialing cycles, expirations, and compliance requirements Identify root causes of enrollment or credentialing delays and implement process improvements Collaborate with leadership to standardize and document processes across revenue cycle functions

Front-End Revenue Cycle Support

Advise and support front desk and intake staff on best practices for eligibility verification, insurance capture, and authorization processes Assist in developing and improving front-end workflows to ensure accurate patient and payer information before services are rendered Identify trends in eligibility or intake errors that contribute to claim denials and recommend corrective actions Support training and guidance for staff related to front-end revenue cycle processes

Billing & Denial Support

Assist with medical billing functions including claim submission, follow-up, and resolution of denials Analyze denial patterns and partner with front-end and credentialling functions to address root causes Work collaboratively with billing staff to ensure clean claim submission and timely reimbursement Support continuous improvement in clean claims rates, A/R performance, and denial reduction

Compliance & Data Integrity

Ensure compliance with HIPAA, CARF, payer requirements, and regulatory guidelines related to credentialing and billing Maintain confidentiality and security of protected health information (PHI) Support audit preparation and documentation of credentialing, enrollment, and revenue cycle processes Promote data accuracy and consistency across systems used for credentialing, billing, and provider management

Other duties as assigned Supervisory Responsibilities None Education RequirementsAssociate degree required; bachelor’s degree in healthcare administration, business or related field preferred.  At least 5 years of related experience may be considered in lieu of degree. Experience Requirements

Minimum of 3-5 years of experience in medical billing, credentialing, payer enrollment, or revenue cycle operations. Demonstrated hands-on experience with provider credentialing and payer enrollment processes. Experience working with Medicare, Medicaid, and commercial payers. Familiarity with eligibility verification and front-end revenue cycle workflows. Experience identifying and resolving claim denials or reimbursement issues.

Qualifications

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Ability to pass a criminal background check. Must maintain a valid driver’s license in preparation for any driving for the agency.

Skills & Abilities

Strong knowledge of credentialing, payer enrollment, and revenue-cycle processes Understanding of how front-end processes impact billing outcomes and denial rates Experience with credentialing systems (e.g. PECOS) and billing/EMR platforms Excellent organizational skills with the ability to track multiple providers, deadlines, and requirements Strong analytical and problem-solving skills with a focus on root cause analysis Ability to design and improve workflow processes High attention to detail and commitment to data accuracy Effective communication skills with the ability to work cross-functionally (billing, intake, clinical, and leadership teams) Strong understanding of HIPAA and payer compliance requirements

Physical Demands The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The ability to regularly sit and talk or hear. The ability to identify the details in numbers. The ability to perform computer work and data entry. The ability to regularly stand, walk, use of hands to finger, handle, or operate objects, tools, or controls The occasional ability to climb, balance, stoop, kneel, crouch, or crawl, and smell. The ability to regularly lift and/or move up to 10 pounds. The ability to occasionally lift and/or move up to 25 pounds. The ability of close vision, distance vision, color vision, peripheral vision, depth perception, and the ability to adjust focus.

Work Environment The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually low to moderate.