Medical Insurance Credentialing Specialist

Accountabilities:: As a Medical Insurance Credentialing Specialist, you will oversee the full lifecycle of provider credentialing, insurance enrollment, and claims management. You will ensure that provider records remain accurate, billing activities meet payer requirements, and reimbursement issues are addressed promptly through effective coordination and follow-up. Prepare and submit credentialing applications for new healthcare providers across commercial insurance carriers, Medicare, Medicaid, and managed care organizations. Manage provider re-credentialing within required timelines to prevent lapses in insurance network participation. Maintain accurate provider information in credentialing databases, payer portals, and related systems. Coordinate with providers to collect required documentation, professional licenses, certifications, and signatures. Review, prepare, and submit medical insurance claims accurately using electronic health record (EHR) and billing systems. Apply appropriate CPT, HCPCS, and ICD-10 codes, including relevant modifiers, in accordance with applicable billing guidelines. Verify patient demographics, insurance eligibility, and coverage details before submitting claims. Apply payer-specific policies, fee schedules, and filing deadlines to support accurate and timely claims processing. Monitor claim status through payer portals, manage claim edits and rejections, and coordinate necessary adjustments. Post insurance payments, contractual adjustments, and write-offs accurately, identifying underpayments and payment discrepancies. Reconcile daily, weekly, and monthly payment reports and maintain accurate billing records. Investigate claim denials and rejections, prepare supporting documentation, and submit timely appeals. Maintain detailed follow-up logs to track outstanding claims through resolution. Ensure compliance with HIPAA, CMS requirements, payer policies, and applicable federal and state regulations. Collaborate with clinical, administrative, and revenue cycle teams to resolve billing and credentialing issues. Serve as a liaison between healthcare providers and insurance payers, resolving enrollment discrepancies and network participation issues. Monitor changes in payer requirements, credentialing policies, and coding guidelines to maintain compliance. Maintain credentialing logs, spreadsheets, databases, and expiration-date trackers to ensure deadlines are met. Audit credentialing files for completeness and accuracy and prepare management reports on application progress, pending items, and compliance status. Identify recurring payer issues and recommend process improvements to strengthen operational efficiency and reimbursement outcomes. Requirements: The ideal candidate combines hands-on medical credentialing and billing experience with a strong understanding of insurance payer processes, coding standards, and healthcare compliance. You should be highly organized, comfortable managing multiple deadlines, and able to communicate effectively with providers, insurance representatives, and internal stakeholders. High school diploma or equivalent required; an associate or bachelor's degree in healthcare administration, business, or a related field is preferred. At least two years of experience in medical credentialing, medical billing, or both, preferably working with multiple insurance payers. Strong working knowledge of commercial insurance, Medicare, Medicaid, and managed care credentialing and reimbursement processes. Familiarity with CAQH ProView, NPPES, PECOS, Availity, payer portals, and EHR or medical billing software. Demonstrated experience preparing accurate claims, resolving denials, following up on outstanding payments, and maintaining compliance with payer requirements. Understanding of CPT, ICD-10, and HCPCS coding systems, including modifier requirements. Knowledge of provider enrollment, re-credentialing procedures, insurance eligibility verification, claim submission deadlines, and payer-specific policies. Medical billing or coding certification, such as Certified Professional Biller (CPB), Certified Professional Coder (CPC), or an equivalent qualification, is an advantage. Excellent attention to detail and a commitment to maintaining accurate, complete, and well-organized records. Strong organizational, time-management, and problem-solving skills, with the ability to manage multiple applications, claims, and deadlines simultaneously. Effective written and verbal communication skills for coordinating with healthcare providers, insurance representatives, patients, and colleagues. Proficiency in credentialing, billing, and documentation systems, with the ability to learn new tools and workflows. Understanding of HIPAA, CMS, NCQA, and other applicable healthcare compliance standards. Ability to work independently in a remote environment while maintaining productivity, accuracy, and consistent follow-through. Benefits: Fully remote work arrangement. Full-time employment. Standard Monday-to-Friday business hours. Opportunity to develop expertise across provider credentialing, medical billing, insurance claims, and revenue cycle operations. Collaborative work with healthcare providers and administrative, clinical, and revenue cycle professionals. Opportunity to contribute to improved reimbursement accuracy, regulatory compliance, and operational efficiency.