Credentialing Specialist

Westside Family Healthcare Inc; Delaware; On-site; USD 52,000 - 70,000; Full time

Benefits offered by this job

Medical insurance

Dental insurance

Vision insurance

401(k) with match

Paid time off

Job summary

Westside Family Healthcare is seeking a Healthcare Credentialing and Billing Specialist to join the Revenue Team. The role centers on credentialing, regulatory compliance, and patient billing for Licensed Independent Providers across our Delaware facilities.

You will manage CAQH profiles, adhere to Joint Commission and HRSA requirements, and generate reports for internal staff. This nonprofit organization emphasizes equal access to quality care and values dedicated teamwork.

Qualifications

• Experience with healthcare data entry and billing processes.
• Knowledge of credentialing/privileging best practices.
• Familiarity with Joint Commission and HRSA requirements.

Responsibilities

• Compile credentialing data for LIPs and maintain records.
• Ensure compliance with accreditation standards.
• Prepare credentialing files for Board and maintain timely updates.
• Generate provider data reports for internal staff and vendors.
• Assist with insurance credentialing and CAQH profile maintenance.

Skills

Data entry

Microsoft Office

Credentialing

Billing principles

Insurance contracting

Credentialing and privileging

Education

High school diploma or GED

Tools

CAQH profiles

Third-party billing systems

Job description

Description

WESTSIDE FAMILY HEALTHCARE IS LOOKING FOR A HEALTHCARE CREDENTIALING AND BILLING SPECIALIST TO JOIN THE REVENUE TEAM.

JOIN THE TEAM THAT CARE!

Westside Family Healthcare is a nonprofit organization that provides high quality primary medical care. The Healthcare Credentialing and Billing Specialist is primarily responsible for credentialing Licensed Independent

Providers (LIPs) with contracted insurance plans. The position supports the HRSA and Joint Commission compliant

initial and ongoing credentialing and privileging of all LIPs within the organization. This role provides broad

support to the Revenue Cycle department with a focus on credentialing, regulatory compliance, and patient billing related

tasks.

Since opening our doors in 1988, Westside has been driven by our mission to improve the health of our communities by providing equal access to quality healthcare. With 240 team members, five health centers, one mobile health unity and over 27,000 patients all across Delaware, Westside is committed to improving health, one patient, one family, one community at a time.

Our Mission:

To improve the health of our communities by providing equal access to quality healthcare

Our Vision

Achieve health equity for all

Our Values:

• Compassion: Lead with compassion
• Service: Serve with humility
• Excellence: Be exceptional
• Empowerment: Empower all people

OUR BENEFITS

Our benefit package includes medical insurance (two plans to choose from), dental insurance (through Guardian Dental), vision insurance, life insurance paid by Westside with the option to purchase more paid, short term disability paid for by Westside, long term disability paid by the employee, a 401(k) retirement plan with a match, and supplemental insurances. We offer a generous PTO package and flexibility to provide work/life balance. Westside Family Healthcare is an Equal Opportunity Employer that values diversity.

CORE RESPONSIBILITIES

1. Compile and maintain current credentialing and privileging data and records for all LIPs in accordance with established policies and procedures.
2. Ensure that the LIP credentialing and privileging processes and policies comply with Joint Commission standards, HRSA and FTCA requirements.
3. Ensure that all credentialing and privileging processes occur in a timely manner, including both initial and renewed privileges and monthly preparation of credentialing files for the Board of Directors.
4. Generate, track, monitor and update all credentialing in established task tracking systems.
5. Create custom reports for internal staff and vendors containing necessary provider data.
6. As a member of the Provider Relations Team, work to support LIP and Family Medicine Residency onboarding, orientation, demographic updates, workflow updates and departures. Serve as a liaison between providers and Westside Family Healthcare leadership.
7. Initiate, track and monitor all insurance credentialing for LIPs with all contracted insurance carriers. This includes creation and ongoing maintenance of CAQH profiles.
8. Generate, track, monitor and update all provider insurance participation using established systems ensuring key staff and vendors can access required data appropriately.
9. Notify appropriate personnel when providers are fully credentialed and contracted with each insurance company.
10. Work closely with provider representatives from each insurance company to ensure that correct provider and practice information is on file, including demographic updates and verifications.
11. Compile billing pool messaging according to established procedures, auditing billing pool messages to determine accuracy of requests and ensuring that third-party billing company takes appropriate actions.
12. Process mail from all sites, which includes sorting documents and appropriately distributing them within the organization when necessary. This leads to the preparation of daily deposits including batching credit card payments received through the mail and uploading them securely to a third-party vendor for processing.
13. Retrieve patient returned statement reports and update spreadsheets to send to appropriate staff on a weekly basis.
14. Retrieve all medical and dental record requests from third-party billing company.
15. Retrieve attorney billing requests received from Health Information Management Supervisor. Continuously update Attorney Billing Information Tracker and forward files to third-party billing company.
16. Complete LabCorp and Quest demographic and diagnosis updates, as required.
17. Provide updated eBrighthealth – ACO Monthly Provider Rosters while documenting each active provider’s OIG verification.
18. Provide updated monthly provider rosters to liability insurance agency/carriers.
19. Reconcile patient roster reports from insurance carriers to ensure accuracy.
20. Track and monitor insurance carrier participation by keeping up to date contracts on file, understanding all plans under carrier umbrellas and ensure Practice Management System is up to date with correct carrier information.
21. Assist with data mining and data entry tasks within Value Based Data Entry Projects.
22. Participates in process development and improvement initiatives within the Revenue Cycle Team.
23. Other duties as assigned.

Requirements

1. High school diploma or GED
2. One year of experience in data entry or data entry training
3. One year of experience using Microsoft Office software suite (Word, Excel, PowerPoint)
4. Proven knowledge of, or experience using, medical billing principles.
5. Experience with insurance contracting and credentialing
6. One year of experience in healthcare provider credentialing and privileging