Credentialing and Billing Specialist

Credentialing & Billing Specialist

Job Description

The Credentialing/Billing Specialist is responsible for insurance credentialing and recredentialing, managing claim submission and denials, and insurance verification processes for outpatient mental health services. This role will be instrumental in our initial efforts to be eligible to bill Medicare, Blue Cross, Viva, and other new payer sources.  They are to ensure JBS compliance with federal and state regulations, accreditation standards, payer requirements, and organizational policies. The specialist works closely with Human Resources, Program Directors, insurance payers, and regulatory agencies to maintain accurate provider records and timely enrollment.

Essential Duties & Responsibilities

• Key figure in Medicare and commercial payers initial provider enrollment and credential process.

• Manage provider credentialing and recredentialing processes with Medicaid, Medicare, and commercial payers.

• Ensure all provider credentials are up to date and compliant with insurance company requirements.

• Validate and maintain provider credentials, including: Medical licenses, DEA registrations, Board certifications, Education and training, work history, Malpractice insurance coverage, and other required documentation.

• Monitor expiration dates and ensure timely renewals of licenses, certifications, and other pertinent information.

• Coordinate provider enrollment and revalidation with Medicare, Medicaid, and commercial insurance carriers.

• Respond to payer requests and resolve credentialing matters.

• Prepare reports for leadership regarding credentialing status and compliance metrics.

• Maintain confidentiality and HIPAA compliance in all credentialing activities.

• Assist with audits and accreditation reviews.

• Perform electronic billing and claims processing for non-Medicaid clients on a routine basis

• Process and post incoming payments for non-Medicaid claims

• Review, analyze, and resolve denied or underpaid non-Medicaid claims in a timely manner

• Track and follow-up on outstanding non-Medicaid claims and correct any errors to secure payment

• Prepare and submit appeals for denied claims, ensuring compliance with payer guideline

Knowledge, Skills & Abilities

• Knowledge of provider credentialing and payer enrollment processes

• Knowledge of CPT codes, ICD-10 coding, and mental health billing regulations, including prior authorization processes

• Familiarity with Medicare, Medicaid, and commercial payer requirements

• Strong attention to detail and organizational skills.

• Excellent written and verbal communication skills.

Qualifications

Education:  High School Diploma or GED required. Associate's or Bachelor's degree in Healthcare Administration, Business Administration, or related field preferred.

Experience

2–3 years in medical billing, with a focus on mental health services. 

1 year experience in insurance credentialing, provider enrollment, and payer requirements.

Certifications (Desired)

Certified Provider Credentialing Specialist (CPCS)

Certification in Medical Billing and Coding (CPC, CPB, or similar)