Credentialing Specialist/Claims Specialist

Job Description

Job Description

Dermatology Specialty Clinic is seeking an experienced, highly organized Medical Provider Credentialing & Claims Billing Specialist to join our administrative/revenue cycle team.

This position combines provider and group credentialing responsibilities with medical insurance claims billing and payer-related functions. The ideal candidate will have strong knowledge of medical billing, insurance claims, payer requirements, provider credentialing, and healthcare revenue cycle processes.

This is a detail-oriented position requiring excellent organization, follow-through, communication skills, and the ability to manage multiple deadlines and priorities.

Provider & Group Credentialing

• Manage initial credentialing and recredentialing for physicians and other healthcare providers.
• Maintain credentialing records for the practice and its providers.
• Manage credentialing and enrollment with Medicare, Medicaid, and commercial insurance payers.
• Maintain and update CAQH profiles and ensure information remains accurate and current.
• Track provider licenses, certifications, registrations, malpractice coverage, and other credentialing requirements.
• Maintain a detailed credentialing calendar and ensure renewals are completed prior to expiration.
• Complete payer enrollment applications, revalidations, demographic updates, and provider/location changes.
• Maintain accurate provider information with insurance payers.
• Follow up with payers regarding credentialing and enrollment status.
• Identify and resolve credentialing issues that could impact provider participation or claim reimbursement.
• Maintain organized documentation of all credentialing and payer enrollment activity.

Medical Claims Billing

• Prepare, review, and submit approximately 1,200 medical insurance claims per week.
• Verify claims for accuracy prior to submission.
• Monitor electronic claim rejections and correct errors promptly.
• Submit corrected claims when necessary.
• Follow up on unpaid and delayed claims.
• Research claim status with insurance payers.
• Review EOBs/ERAs and identify payment discrepancies, denials, and underpayments.
• Assist with insurance A/R and denial management.
• Communicate with insurance companies regarding claim status, payment, denials, and documentation requirements.
• Maintain accurate documentation of billing and payer activity.

Medical Records & Payer Requests

• Process medical record requests required by insurance payers to support claims.
• Obtain and submit appropriate medical documentation within payer deadlines.
• Coordinate with clinical and medical-records staff when additional documentation is required.
• Track outstanding medical-record requests to ensure timely completion.
• Respond to payer requests for additional documentation related to claims.

Insurance Payer Audits

• Assist with insurance payer audits and medical record requests.
• Gather claims, medical records, billing documentation, and other information requested by payers.
• Monitor audit deadlines and ensure timely submission of requested documentation.
• Maintain records of payer audit requests and responses.
• Communicate internally regarding documentation needed to respond to audits.
• Track audit outcomes and identify recurring payer issues that may require operational or billing changes.

Patient Accounts & Front Desk Support

• Assist with patient account balance questions and insurance-related inquiries.
• Respond to questions from front-desk staff regarding insurance eligibility, claim status, patient balances, and insurance payments.
• Research patient accounts and provide accurate information to front-office personnel.
• Assist with patient collections and payment-related questions when needed.
• Maintain professional and courteous communication with patients, providers, front-office staff, and insurance representatives.

Qualifications

Required:

• 2+ years of experience in medical billing, insurance claims, healthcare revenue cycle, credentialing, or a related healthcare administrative position.
• Working knowledge of medical insurance claims and payer processes.
• Strong computer and data-entry skills.
• Excellent attention to detail and organizational skills.
• Ability to manage multiple deadlines and priorities.
• Strong written and verbal communication skills.
• Ability to maintain confidentiality and handle protected health information appropriately.
• Ability to independently follow up with insurance payers and resolve outstanding issues.

Preferred:

• Experience with provider credentialing and recredentialing.
• Experience with CAQH.
• Experience with Medicare, Medicaid, and commercial insurance payer enrollment.
• Experience with medical billing for a specialty practice.
• Experience with insurance denials, appeals, and A/R.
• Experience responding to payer audits and medical-record requests.
• Experience with electronic claims, ERAs, EOBs, and payer portals.
• Dermatology or other specialty-practice billing experience.

Skills & Attributes

The successful candidate will be:

• Highly organized and deadline-driven
• Detail-oriented
• Self-motivated and accountable
• Comfortable working independently
• Professional and customer-service oriented
• Able to communicate effectively with providers, insurance companies, patients, and front-office staff
• Able to prioritize work in a high-volume medical practice
• Proactive in identifying problems before they affect reimbursement
• Comfortable working with confidential patient and provider information

Position Summary

This position plays an important role in maintaining the financial and operational health of the practice. The employee will have responsibility for both provider/group credentialing and medical insurance claims billing, with additional responsibilities involving A/R, payer communications, medical-record requests, payer audits, and front-office insurance support.

The ideal candidate will understand that successful medical billing extends beyond submitting a claim. Accurate credentialing, timely follow-up, proper documentation, payer compliance, and effective communication are all essential to ensuring claims are processed and paid appropriately.

\nCompany Description

We are located in Arlington, TN and Germantown, TN along with offices in Olive Branch, MS and Oxford, MS.

Company Description

We are located in Arlington, TN and Germantown, TN along with offices in Olive Branch, MS and Oxford, MS.