Credentialing & Billing Specialist

Description

We're building 'the' Teaching Hospital for pediatric therapy - a category of one by driving excellence in outcomes, developing clinicians, building payer trust, and embedding systems across what we do.

As a member of the Revenue Cycle Management Team, the Credentialing & Billing Specialist supports two critical functions that directly impact timely reimbursement and access to care: billing and provider credentialing.

This role combines hands-on healthcare billing responsibilities with a strong focus on credentialing application preparation, submission, tracking, and payer follow-up. The ideal candidate is highly organized, detail-oriented, persistent, and comfortable managing multiple payer requirements and deadlines at the same time.

Success in this role means claims are submitted accurately and timely, credentialing applications move forward without unnecessary delays, and payer issues are actively followed through to resolution. Your work helps prevent billing delays and denials, expands provider capacity, supports cash flow, and ensures families can access services as quickly as possible.

• Prepare, review, and submit claims accurately in compliance with payer requirements, coding standards, and internal policies.
• Ensure services are billed within established timelines, targeting an average of five days from the date of service.
• Monitor daily billing queues and prioritize work to ensure timely claim submission.
• Re-bill claims promptly when notified of insurance, authorization, credentialing, or other changes.
• Monitor clearinghouse rejections, research errors, make necessary corrections, and resubmit claims promptly.
• Identify billing issues related to provider enrollment or credentialing and collaborate with the appropriate RCM team members to resolve them.
• Maintain accurate documentation of billing activity and outstanding issues.

• Prepare and submit new provider credentialing, enrollment, and re-credentialing applications to commercial and government payers.
• Gather and verify all documentation required for payer applications to ensure submissions are complete and accurate.
• Maintain provider demographic and credentialing information, including CAQH profiles, NPI information, licenses, certifications, and other required records.
• Actively track applications from submission through completion, following up consistently with payers until enrollment is finalized.
• Contact payers by phone, portal, email, or other available channels to obtain application status, identify missing information, resolve outstanding requirements, and move applications forward.
• Document payer contacts, reference numbers, application status, next steps, and required follow-up dates.
• Respond promptly to payer requests for additional information or documentation.
• Identify applications that are stalled or exceeding expected turnaround times and elevate appropriately.
• Monitor credentialing and re-credentialing deadlines to prevent lapses in provider participation.
• Assist with payer rosters and provider directory information to ensure approved providers are accurately reflected.
• Communicate clearly with providers and internal teams when additional information is needed or when credentialing status changes.
• Maintain organized, accurate, and audit-ready credentialing records.

• Manage a high-volume workload while maintaining accuracy, organization, and appropriate follow-up.
• Maintain clear documentation so the current status and next action for billing and credentialing items can be easily identified.
• Collaborate with Credentialing, Contracting, Eligibility, Authorization, Billing, and AR teams to prevent front-end issues from becoming claim delays or denials.
• Recognize recurring payer or process issues and escalated trends that may require broader resolution.
• Uphold HIPAA, confidentiality, payer, and regulatory requirements in all work.
• Contribute to process improvement initiatives across the revenue cycle.

• Average Days to Bill: 5 days or fewer, with 75% of services billed within the same month.
• First Pass Acceptance Rate: =90% clean claim acceptance.
• Credentialing Application Accuracy: =95% of applications accepted without avoidable corrections or missing information.
• Credentialing Follow-Up: 100% of active applications followed up according to established payer-specific or departmental timelines.
• Credentialing Turnaround: Applications completed within established payer and organizational expectations, with delays proactively identified and escalated.
• Documentation: Accurate and current status, follow-up, and next-action documentation maintained for assigned credentialing applications.
• Error Prevention: Active identification and resolution of billing and credentialing issues that could delay claims or provider readiness.

• High school diploma required;
  Associate's or Bachelor's degree in healthcare administration,…