Billing & Credentialing Specialist

JOB SUMMARY The Clarity Psychological Testing team is seeking a new Billing and Credentialing Specialist. This is a full-time, fully-remote, multi-faceted role.

The team member in this position will play a key role in the success of the Practice and is responsible for managing and overseeing the coding, billing and clinician credentialing processes along with company credentialing with CMS and private insurance companies.

This role involves submitting and following up on insurance claims, monthly reporting on revenue cycle management, working with insurance companies, and ensuring that all healthcare providers are properly credentialed and able to bill for services.

The employee in this position must have a thorough understanding of healthcare billing in the Behavioral Health market, current working knowledge of codes for telehealth, best practices and standard billing procedures, applicable insurance regulations, and credentialing processes in the US healthcare system.

The Billing & Credentialing Specialist works autonomously and is required to exercise a high level of self-motivation, use good judgment, and must be comfortable making independent decisions.

ESSENTIAL RESPONSIBILITIES INCLUDE Billing and Claims Management : Prepare and submit billing data and medical claims to insurance companies.

Ensure the accuracy and completeness of all coding and billing information. Follow up on unpaid claims and resolve billing issues.

Manage the appeals process for denied claims. Maintain up-to-date records of billing activities. Submit and track support tickets to the EHR system vendor to address any technical issues or system enhancements.

Coordinate and schedule final appointments for patients, ensuring all necessary preparations are completed. Credentialing : Coordinate the credentialing process for all healthcare providers, ensuring timely and accurate completion.

Maintain current knowledge of credentialing requirements for all providers. Maintain working knowledge of current coding schedules applicable to virtual diagnostics Keep accurate records of credentialing information and ensure all documents are up to date.

Liaise with healthcare providers, insurance panels, and other entities as required. Facilitate the input of new staff and providers into the Electronic Health Record (EHR) system and manage their access permissions.

Medical Coding Assigning Codes : Reviewing medical records and assigning appropriate alphanumeric codes to diagnoses and services using standard coding systems such as ICD-10-CM (International Classification of Diseases, 10th Revision, Clinical Modification) for diagnoses and CPT (Current Procedural Terminology) or HCPCS (Healthcare Common Procedure Coding System) for procedures and services.

Compliance : Ensuring coding compliance with regulatory requirements including those set by government agencies such as Centers for Medicare & Medicaid Services (CMS) and private insurers.

Adhering to official coding guidelines and healthcare regulations to prevent fraudulent or erroneous claims. Accuracy : Maintaining accuracy in code assignment to reflect the patient's condition and the services provided.

Ensuring that codes reflect the clinician’s documentation accurately and completely. Record Keeping : Keeping detailed records of code assignments and maintaining patient confidentiality in accordance with HIPAA (Health Insurance Portability and Accountability Act) regulations.

Communication : Collaborating with healthcare providers and other staff to clarify documentation and resolve coding-related issues.

Effective communication is crucial for accurate coding and billing processes. Audit Preparation : Assisting in internal and external coding audits to ensure compliance with coding guidelines and accuracy of coded data.

Providing documentation and explanations as needed during audits. Continuous Education : Staying updated on changes in coding guidelines, regulations, and healthcare industry practices through ongoing education and training.

Maintaining certification through continuing education requirements. Revenue Cycle Management : Supporting revenue cycle management by accurately translating medical services into codes for billing and reimbursement purposes.

Maximizing revenue by ensuring complete and accurate documentation and coding. Quality Improvement : Identifying opportunities for process improvement in coding workflows and documentation practices to enhance accuracy, efficiency, and compliance.

Ethical Conduct : Upholding professional and ethical standards in coding practices, including integrity, honesty, and confidentiality.

Stay informed about current healthcare regulations, including HIPAA, and ensure compliance. Understand and comply with insurance and healthcare regulations and requirements.

Ensure all billing and credentialing processes meet state and federal standards. Process and fulfill requests for medical records in compliance with privacy and confidentiality regulations.

Compliance and Regulations : Stay informed about current healthcare regulations, including HIPAA, and ensure compliance.

Understand and comply with insurance and healthcare regulations and requirements. Ensure all billing and credentialing processes meet state and federal standards.

Process and fulfill requests for medical records in compliance with privacy and confidentiality regulations. Customer Service : Provide support and answer inquiries from patients, healthcare providers, and insurance companies.

Resolve any issues related to billing, insurance, or credentialing. Reporting & Administration : Generate and analyze monthly reports on billing activities, insurance reimbursements, and credentialing status.

Assist with audits and investigations related to billing and credentialing. EXPERIENCE & QUALIFICATIONS Certified Medical Coder (preferred) with a minimum of 3-5 years’ experience Associate or bachelor’s degree in healthcare administration, finance, or related field preferred.

Minimum of one (1) year's experience with Massachusetts Medicaid. In-depth knowledge of medical billing procedures, insurance policies, and credentialing processes.

Familiarity with healthcare laws, regulations, and standards, including HIPAA. Excellent organizational skills and attention to detail.

Strong communication and interpersonal skills. Proficiency in medical billing software and electronic medical records (EMR) systems, preferably InSync or AdvancedMD. Powered by JazzHR