Credentialing and Billing Specialist

Job Description

Job Description

Description:

SUMMARY

The Credentialing and Billing Specialist is responsible for coordinating provider credentialing, recredentialing, enrollment, and billing support activities for CTCLUSI Health Services. This position ensures providers are properly credentialed, enrolled, and maintained with federal, state, Tribal, and commercial payers while supporting accurate and timely billing operations. The Credentialing and Billing Specialist works collaboratively with providers, clinical leadership, Revenue Cycle staff, and external agencies to maintain compliance with payer requirements and support efficient reimbursement processes across medical, dental, behavioral health, pharmacy, and ancillary services.

Note: This position is fully remote and requires the employee to maintain a secure, confidential workspace that complies with HIPAA and CTCLUSI confidentiality requirements.

PRINCIPAL ACTIVITIES & RESPONSIBILITIES:

• Coordinates provider credentialing, recredentialing, privileging, and enrollment activities with Medicare, Medicaid, commercial insurance plans, Tribal programs, and other payer entities.
• Maintains provider enrollment records and ensures timely submission of applications, renewals, updates, and supporting documentation.
• Tracks credentialing expiration dates including licenses, certifications, DEA registrations, malpractice coverage, and other required provider documentation.
• Communicates with providers and leadership regarding credentialing requirements, missing documentation, and enrollment status updates.
• Maintains accurate provider files and credentialing records in accordance with regulatory and organizational requirements.
• Assists with billing functions including claim review, charge entry support, claim corrections, payment posting support, denial follow-up, and insurance verification activities.
• Monitors payer enrollment status to ensure uninterrupted billing and reimbursement.
• Assists with resolving credentialing-related billing holds, denials, and reimbursement delays.
• Coordinates with Revenue Cycle, Human Resources, Compliance, Medical Staff, and provider leadership regarding credentialing and billing requirements.
• Ensures compliance with HIPAA, CMS, Medicare, Medicaid, Tribal, and payer regulations.
• Maintains confidentiality of patient, employee, provider, and Tribal information.
• Assists with audits, reporting requirements, and payer requests related to provider credentialing and billing activities.
• Participates in process improvement efforts to support operational efficiency and reimbursement optimization.
• Assists with training and education related to credentialing, enrollment, and billing requirements.
• Collaborates efficiently and effectively while consistently demonstrating professionalism and maintaining positive, respectful relationships with internal teams, external partners, and Tribal members.
• Other duties as directed by management.

LEVEL OF AUTHORITY & RESTRICTIONS

• This position requires working independently without overseeing others, with no authority in decision-making.
• This position has no formal supervisory responsibilities or authority but may support training efforts and provide guidance to staff within established procedures.

PHYSICAL & MENTAL DEMANDS

• Must be able to sit for extended periods while performing computer-based work.
• Must be able to use hands and fingers to operate computer equipment and office tools.
• Vision abilities required include close vision and the ability to adjust focus.
• Must possess attention to detail and the ability to maintain concentration for extended periods.
• May occasionally lift or carry office materials up to 20 pounds.

WORKING CONDITIONS & ENVIRONMENT

• This is a fully remote position requiring regular and reliable internet access and the ability to work independently in a secure home office environment.
• Employee must maintain a private workspace sufficient to protect confidential information and comply with HIPAA requirements.
• Extensive computer and telephone use required throughout the workday.
• Moderate noise level with frequent interruptions and competing priorities.
• May require travel for meetings, trainings, audits, conferences, or Tribal events.
• Must be available during established business hours and maintain consistent communication with supervisors and employees.
• May require occasional evening or weekend work depending on operational needs.

MINIMUM JOB REQUIREMENTS

• Must be 18 years of age or older.
• High School Diploma or equivalent.
• Minimum of two (2) years of experience in provider credentialing, medical billing, healthcare administration, or related healthcare operations.
• Experience with Medicare, Medicaid, commercial payer enrollment, and credentialing requirements.
• Knowledge of medical terminology, healthcare reimbursement processes, and insurance billing practices.
• Knowledge of Medicare, Medicaid, commercial insurance, FQHC, IHS, and Tribal billing practices.
• Experience with EHR and Practice Management systems.
• Strong attention to detail and organizational skills.
• Ability to maintain confidentiality and exercise sound judgment.
• Must demonstrate the ability to work successfully in a remote environment with minimal direct supervision.
• Experience and proficiency in the use of Microsoft products (Excel, Outlook, PowerPoint, Word, etc).
• Ability to communicate clearly and effectively in English, verbally, in writing or by other acceptable means.
• This position is considered a non-covered role per the CTCLUSI Background Investigations Policy. A state criminal background check and fingerprint-based background check will be required as a condition of employment.
• This position is subject to pre-employment and other authorized drug and alcohol testing in accordance with company policy.
• Must have employment eligibility in the U.S.
• Indian preference will be observed in the hiring process.