Credentialing & Denials Specialist - Revenue Integrity

Critical Care Pulmonary & Sleep Associates; Lakewood (CO); On-site; USD 30,000 - 47,000; Full time

Benefits offered by this job

Medical benefits

Dental and vision benefits

PTO and holidays

401k with company contribution

Life and AD&D benefits

Disability insurance

Job summary

Critical Care Pulmonary & Sleep Associates in Colorado's Denver metro area is seeking a Credentialing and Denials Specialist to manage provider enrollment, credentialing, and privileging across commercial payers and government programs. This role ensures timely reimbursement and uninterrupted patient care while supporting ongoing compliance.

The position involves researching and appealing denied claims, monitoring payer policies, documenting investigations, and collaborating with billing,

Qualifications

• Minimum of two (2) years of experience in provider credentialing, payer enrollment, medical billing, denial management, or revenue cycle operations.
• Demonstrated experience researching, appealing, and resolving insurance claim denials.
• Working knowledge of medical terminology, payer guidelines, credentialing requirements, and healthcare reimbursement methodologies.
• Excellent analytical, organizational, problem-solving, and critical thinking skills.
• Strong written and verbal communication skills.
• Proficiency in Microsoft Outlook, Word, Excel, internet research, and payer portals.
• High School Diploma or GED required.

Responsibilities

• Ensure CCPSA providers are credentialed, enrolled, appointed, and privileged with commercial and government payers, hospitals, and other healthcare organizations to support uninterrupted clinical operations and timely reimbursement.
• Complete provider enrollment, credentialing, recredentialing, revalidation, appointment, privileging, and ongoing maintenance activities with commercial and government payers, hospitals, and other healthcare organizations.
• Coordinate provider onboarding activities related to credentialing and privileging, including hospital application requirements and other required pre-start activities, as applicable.
• Maintain provider credentialing records and monitor compliance with licenses, certificates, DEA registrations, malpractice coverage, continuing education, and other credentialing requirements.
• Maintain accurate provider information within credentialing systems, payer portals, hospital credentialing systems, CAQH, and other required databases.
• Ensure all credentialing files meet standards set by the NCQA, TJC, CMS, hospitals, and payer-specific guidelines.
• Serve as the primary point of contact for provider credentialing, enrollment, appointment, and privileging questions.
• Review assigned denial work queues and investigate denied claims for accurate and timely resolution.
• Research and appeal insurance claim denials through review of coding, medical records, payer contracts, reimbursement guidelines, and applicable documentation.
• Maintain advanced knowledge of payer websites, reimbursement guidelines, and appeal processes for commercial and government payers, including Medicare, Medicaid, Medicare Advantage, Tricare, VA, and other payer plans.
• Analyze denial trends and identify root causes to proactively reduce future denials.
• Escalate denial issues and communicate recurring trends or payer policy changes to leadership.
• Ensure appeals are submitted within payer filing deadlines.
• Stay current on payer policies, reimbursement regulations, and credentialing requirements.
• Assist with educating team members regarding payer updates, denial trends, and process improvements.
• Accurately document denial investigations, appeals, credentialing activities, and resolutions within appropriate systems.
• Collaborate with providers, payers, coding, billing, and other internal teams to resolve reimbursement issues and support efficient revenue cycle operations.
• Participate in quality improvement initiatives and projects that enhance revenue cycle performance.
• Perform other duties as assigned by the manager.

Skills

Analytical skills

Credentialing experience

Attention to detail

Customer service

Communication skills

Time management

Microsoft Office

Education

High School Diploma or GED

Tools

EPIC Resolute Professional Billing

Job description

Critical Care Pulmonary & Sleep Associates in Colorado's Denver metro area is seeking a Credentialing and Denials Specialist to manage provider enrollment, credentialing, and privileging across commercial payers and government programs. This role ensures timely reimbursement and uninterrupted patient care while supporting ongoing compliance.

The position involves researching and appealing denied claims, monitoring payer policies, documenting investigations, and collaborating with billing,