Medical Insurance Credentialing Specialist

New

JobgetherHealthcare administration

Based in CanadaFull-TimeJunior

Salary not disclosed

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Job Details

Experience: At least two years of experience in medical credentialing, medical billing, or both

Have a high school diploma or equivalent; an associate or bachelor's degree in healthcare administration, business, or a related field is preferred.
Have at least two years of experience in medical credentialing, medical billing, or both, preferably with multiple insurance payers.
Have working knowledge of commercial insurance, Medicare, Medicaid, and managed care credentialing and reimbursement processes.
Be familiar with CAQH ProView, NPPES, PECOS, Availity, payer portals, and EHR or medical billing software.
Have experience preparing claims, resolving denials, following up on outstanding payments, and meeting payer requirements.
Understand CPT, ICD-10, and HCPCS coding systems, including modifier requirements.
Understand provider enrollment, re-credentialing, insurance eligibility verification, claim deadlines, and payer-specific policies.
Understand HIPAA, CMS, NCQA, and other applicable healthcare compliance standards.
Be able to manage multiple applications, claims, and deadlines with strong organization, time management, and problem-solving skills.
Maintain accurate and well-organized records with strong attention to detail.
Communicate effectively in writing and verbally with providers, insurance representatives, patients, and colleagues.
Be able to work independently in a remote environment with consistent follow-through.
Medical billing or coding certification, such as CPB, CPC, or an equivalent qualification, is an advantage.

Prepare and submit credentialing applications for providers across commercial insurance carriers, Medicare, Medicaid, and managed care organizations.
Manage provider re-credentialing within required timelines and maintain accurate information in credentialing databases and payer portals.
Collect required provider documentation, licenses, certifications, and signatures.
Prepare and submit medical insurance claims using EHR and billing systems, applying CPT, HCPCS, and ICD-10 codes and relevant modifiers.
Verify patient demographics, insurance eligibility, and coverage before claim submission.
Monitor claim status, manage edits and rejections, and coordinate claim adjustments.
Post insurance payments, contractual adjustments, and write-offs; identify underpayments and reconcile payment reports.
Investigate denials, prepare supporting documentation, submit appeals, and track outstanding claims through resolution.
Maintain credentialing logs, spreadsheets, databases, and expiration trackers; audit files and prepare management reports.
Coordinate with providers, payers, and internal teams to resolve enrollment and billing issues, monitor requirements, and recommend process improvements.

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