Credentialing and Follow-Up Specialist

Position Summary

The Credentialing and Follow Up Specialist roles combines three key areas: provider credentialing, medical coding, and insurance account receivable follow-up. The Credentialing and Follow Up Specialist is responsible for ensuring providers are enrolled with insurance payers, that services are coded correctly to mitigate denials, and that any delayed claims are resolved efficiently. This role is essential for maintaining cash flow, reducing aged accounts receivable, and ensuring compliance.

Essential Duties and Responsibilities

The essential functions include, but are not limited to the following:

• Manage the end-to-end credentialing and re-credentialing process for physicians and advance practice providers with Medicare, Medicaid, and commercial insurance payers.
• Collect and verify provider credentials (licenses, certifications, education, work history, malpractice insurance, etc.)
• Prepare and submit complete and accurate CAQH profiles initial/renewal applications.
• Liaise with payers to track application status and ensure timely approval.
• Maintain up-to-date provider information in credentialing databases, CAQH, and payer portals.
• Monitor expirations of licenses and certifications to ensure uninterrupted billing eligibility.
• Utilize knowledge of CPT, HCPCS, and ICD-10 coding guidelines to perform pre-bill audits on complex encounters.
• Identify and correct coding errors, building issues, and modifiers misuse before claims submission to prevent denials.
• Serve as a coding resource for providers and billing staff, offering guidance on documentation requirements and code section.
• Analyze denial trends related to coding and provide feedback and education to prevent future occurrences.
• Proactively manage and resolve unpaid and denied claims for insurance carriers.
• Investigate denials and payment delays; determine root cause (e.g., credentialing, coding, eligibility, timely filing).
• Prepare and submit accurate and compelling appeals for denials related to medical necessity, coding, and lack of credentials.
• Work directly with insurance provider representatives via phone, email, and online portals to resolve complex account issues.
• Document all follow-up activities clearly and concisely in Epic.