Billing and Credentialing Specialist

Clinivoy LLC; Irvine (CA); On-site; USD 60,000 - 80,000; Full time

Job summary

Clinivoy LLC is seeking a Billing & Credentialing Specialist in Irvine, CA to manage the full revenue cycle for infusion services. You will perform benefits investigations, verification, and accurate claim submission while handling denials and appeals to optimize reimbursement.

You will also manage provider credentialing/enrollment with Medicare, Medi-Cal, and commercial payers, maintain credentialing data, and collaborate with PA teams to ensure timely activations and compliant billing

Qualifications

• Minimum 2 years in medical records or a similar setting preferred.
• Infusion clinic experience preferred.
• Experience dealing with third-party billers preferred.
• Strong communication, interpersonal, and organizational skills required.

Responsibilities

• Verify medical benefits for infusion services and perform benefit investigations.
• Process and submit CMS-1500 and UB-04 claims for facility and professional billing.
• Apply proper coding for infusion services (J-codes, S-codes, NDC crosswalks, CPT 96365–96379, 96401–96417).
• Manage buy-and-bill billing, ASP pricing, wastage, and payer-specific rules.
• Monitor claim status, AR collections, and resolve denials; handle appeals.
• Credentialing and enrollment for providers with Medicare, Medi-Cal, and commercial plans; maintain CAQH/NPPES/PECOS.
• Coordinate with Prior Authorization team; ensure timely submissions and approvals.
• Maintain communications with payers and providers to ensure smooth billing and activation of privileges.

Skills

Verbal and written communication

Interpersonal skills

Negotiation

Conflict resolution

Organizational skills

Attention to detail

Analytical thinking

Problem-solving

Prioritization & delegation

Integrity & confidentiality

Job description

The Billing & Credentialing Specialistis responsible formanaging the full revenue cycle for infusion services, including benefits investigation, verification,accurateclaim submission, denial resolution, and AR follow-up. This role handles complex buy-and-bill infusion billing , including J-codes, S-codes, NDC crosswalks, biologics, and time-based infusion services.

Additionally, the specialist manages provider credentialing and enrollment with Medicare, Medi-Cal, and commercial payers, ensuring compliance andtimelyactivation. The position supports patients, providers, and internal departments tooptimizereimbursement andmaintaincontinuity of care.

Key Accountabilities:

Medical Benefits Billing & Revenue Cycle Management

Verify medical benefits for infusion services, including specialty biologics, IVIG, and injectable therapies.

Complete detailed benefit investigation (BI) for medical benefits , deductible, OOP, copay, and coverage limitations.

Process, correct, andsubmitclaims using CMS-1500 and UB-04 forms for facility and professional billing.

Apply proper coding for infusion services including:

J-codes / S-codes

NDC conversions & crosswalks

Infusion CPT codes (96365–96379, 96401–96417)

Manage buy-and-bill billing including ASP pricing, wastage documentation, and payer-specific requirements.

Monitor claim status and process secondary or tertiary claims asrequired.

Perform comprehensive AR collections , including tracking outstanding balances and resolving unpaid or underpaid claims.

Research and resolve claim errors, coding issues, and payer-specific infusion policies.

Manage prior authorization follow-up with the PA team and ensure claims are billed compliant with authorization terms.

Communicate with payers to resolve rejections, eligibility discrepancies, and coverage issues.

Denials, Appeals & Reconsiderations

Review, analyze, and resolve claim denials related to medical necessity, coding, benefit coverage, or documentation.

Prepare andsubmitappeal packets including clinical justifications, medical records, infusion notes, and prior authorization details.

Draft high-quality appeal letters based on denial category and payer requirements.

Track appeal turnaround times and follow up with payers until resolution.

Coordinate with prescribers to obtain clinical notes, labs, andadditionaldocumentsrequiredforapprovalsor appeals.

Complete credentialing and enrollment for providers with Medicare, Medi-Cal, and commercial insurance plans.

Maintain and update CAQH , NPPES , PECOS , and payer portal information.

Initiate and manage re-credentialing processes and track expiring documents.

Maintain an organized,compliantcredentialing database.

Communicate with insurers and internal teams to ensuretimelyactivation of provider billing privileges.

Division team/specific Accountabilities:

Communicate with patients to gather information required forbenefitsverification, billing setup, financial counseling, and to ensureaccurateprocessing of infusion orders and authorizations. Build clear, supportive communication that promotes trust and patient loyalty.

Investigate and verify medical benefits for infusion and specialty biologic services, including deductible, co-pay, out-of-pocket costs, prior authorization requirements, site-of-care restrictions, step therapy, and medical policy guidelines.

Coordinate with manufacturer financialassistanceprograms , copay foundations, and internal support teams to help eligible patients obtain financial support, copay cards, or patient-assistance funding whenappropriate.

Work closely with the Prior Authorization team by providing allrequiredclinical and documentation updates, ensuringtimelysubmission, tracking authorization progress, andmaintainingconsistent communication with the patient and provider.

Facilitate denial and appeal processes by requesting denial documentation, gathering clinical records, and preparing appeal packets. Compose appeal letters based on denialreason, medical necessity, and the patient’s clinical condition.

Conduct regular status checks with insurance companies on pending authorizations, appeals, and claim adjudications. Obtain approval information, document outcomes, and update copay or financialassistancestatuses whenrequired.

Identify, track, and elevate service-delaying issues related to prior authorizations, benefit determinations, clinical documentation, or financialassistancegaps to ensure uninterrupted patient therapy andtimelyinfusion scheduling.

Build andmaintaineffective working relationships with prescriber offices, referral partners, and clinical staff treating assigned disease states. Provide ongoing updatesregardingcase status, authorizations, and payer requirements.

Complete all required assessments or checklists mandated bymanufacturerprograms, payer requirements, or internal workflow processes to ensure compliance with program standards.

Review and respond to notifications of patients who require financialassistance , providing them with available program options, community resources, and support to help minimize out-of-pocket burden.

Assistpatients with submittingfinancialassistanceapplications , including obtaining consent forms, uploading documentation, completing electronic applications, and following up with financialassistanceprograms to prevent therapy interruptions.

Maintaintimelyupdates on pending or unfilled infusion orders , keeping prescription and authorization statuses current in the system at least every48 hoursor per department protocol.

Ensure that all activitiescomply withorganizational standards, payer guidelines,manufacturerprogram requirements, and HIPAA . Deliver service in a manner that meets the highest standards of quality, accuracy, and patient care.

Experience:

A minimum of 2 years of prior experience in a medical records department or like setting preferred.

Priorexperience with anInfusionclinic. (preferred)

Dealing with third party billers. (preferred)

Excellent verbal and written communication skills.

Excellent interpersonal, negotiation, and conflict resolution skills.

Excellent organizational skills and attention to detail.

Strong analytical and problem-solving skills.

Ability to prioritize tasks and to delegate them when appropriate.

Ability to act with integrity, professionalism, and confidentiality.