Medical Insurance Credentialing Specialist

Thrivelab Co.; Stati Uniti; Remoto; USD 55.000 - 75.000; Tempo pieno

Descrizione del lavoro

Thrivelab Co. is seeking a highly skilled Medical Insurance Credentialing Specialist to manage provider credentialing, enrollment, and billing across multiple payers in a remote setting. You will coordinate with providers, submit applications, and ensure timely reimbursements.

The role emphasizes accuracy, regulatory compliance, and effective communication with payers and clinical staff, with opportunities to implement process improvements and enhance credentialing workflows.

Competenze

• High school diploma or equivalent required; associate or bachelor’s degree preferred.
• Certification in medical billing/coding (CPB, CPC, or equivalent) is a plus.
• Minimum 2 years of experience in medical credentialing and/or billing, preferably across multiple payers.
• Strong working knowledge of CAQH ProView, NPPES, PECOS, Availity, payer portals, and EHR/billing software.
• Proven track record of accurate claim submission, denial resolution, and maintaining compliance with payer requirements.

Mansioni

• Prepare and submit credentialing applications for new providers to a variety of insurance payers.
• Complete re-credentialing processes according to payer timelines to avoid network participation lapses.
• Maintain accurate and up-to-date provider records in credentialing databases and payer portals.
• Coordinate with providers to obtain necessary documentation, certifications, licenses, and signatures.
• Accurately review, prepare, and submit medical insurance claims for a variety of payers using EHR/billing systems.
• Ensure proper coding using CPT, HCPCS, ICD-10, and modifier guidelines.
• Validate patient demographics, insurance eligibility, and coverage details before claim submission.
• Navigate multiple payer portals for claim status, adjustments, and appeals.
• Post payments, contractual adjustments, and write-offs accurately.
• Identify and address underpayments and payment discrepancies.
• Reconcile daily/weekly/monthly payment reports to ensure accuracy.
• Research and analyze claim denials and rejections.
• Prepare and submit timely appeals with appropriate documentation.
• Maintain follow-up logs to track outstanding claims until resolved.
• Adhere to HIPAA, CMS, and payer compliance guidelines.
• Maintain accurate and complete billing records in accordance with office policies.
• Stay updated on insurance and coding changes through continuing education.

Conoscenze

Attention to detail

Organizational skills

Time management

Problem solving

Communication skills

Multitasking

Formazione

High school diploma or equivalent

Associate or Bachelor’s degree in healthcare administration or related field

Medical billing/coding certification (CPB, CPC)

Strumenti

CAQH ProView

NPPES

PECOS

Availity

Payer portals

EHR/billing software

Descrizione del lavoro

Medical Insurance Credentialing Specialist

Thrivelabwas founded by Joshua Host after a serious biking accident showed thehealing power of bioidentical hormone replacement therapy (BHRT). Longafter he had physically healed, Joshua battled significant cognitionissues. Even basic math was a struggle. Numerous brain specialists andprescription drug regimens didn’t help. Then Joshua read an articlepublished by Harvard Medical School about the treatment of traumaticbrain injuries with BHRT. After just 30 days, he felt like his old self.

Joshua became fascinated with BHRT andsoon realized there’s a hormone imbalance epidemic underway caused byenvironmental toxins, chronic stress, diet and current lifestyles. Tomake hormone replacement therapy and optimization personalized,accessible, affordable and convenient for both men and women, Joshuafounded Thrivelab in 2020.

Sincethen, Thrivelab has built an experienced medical team ofboard-certified providers who follow a proven process supported byevidence-based treatment and testing protocols. The result:groundbreaking hormone and testosterone balancing programs and naturalproducts for bioidentical hormone replacement therapy that can alleviateage-related symptoms to restore youthful vitality.

Job Description

This is a remote position.

We are seeking a highly skilled and detail-oriented Medical Insurance Credentialing Specialist with proven experience working with multiple payers, including commercial insurance carriers, Medicare, Medicaid, and managed care organizations. The ideal candidate will be responsible for managing the full lifecycle of provider credentialing, re-credentialing, and medical billing processes. This includes preparing, submitting, and following up on claims, ensuring timely and accurate reimbursement, and maintaining compliance with payer-specific requirements and federal and state regulations.

Key Responsibilities

• Prepare and submit credentialing applications for new providers to a variety of insurance payers.
• Complete re-credentialing processes according to payer timelines to avoid network participation lapses.
• Maintain accurate and up-to-date provider records in credentialing databases and payer portals.
• Coordinate with providers to obtain necessary documentation, certifications, licenses, and signatures.
• Accurately review, prepare, and submit medical insurance claims for a variety of payers using electronic health record (EHR) and billing systems.
• Ensure proper coding using CPT, HCPCS, ICD-10, and modifier guidelines.
• Validate patient demographics, insurance eligibility, and coverage details before claim submission.
• Apply knowledge of different payer rules, fee schedules, and claim filing limits.
• Navigate multiple payer portals for claim status, adjustments, and appeals.
• Manage claim edits and rejections based on payer-specific requirements.
• Post payments, contractual adjustments, and write-offs accurately.
• Identify and address underpayments and payment discrepancies.
• Reconcile daily, weekly, and monthly payment reports to ensure accuracy.
• Research and analyze claim denials and rejections.
• Prepare and submit timely appeals with appropriate documentation.
• Maintain follow-up logs to track outstanding claims until resolved.
• Adhere to HIPAA, CMS, and payer compliance guidelines.
• Maintain accurate and complete billing records in accordance with office policies.
• Stay updated on insurance and coding changes through continuing education.
• Work closely with clinical, administrative, and revenue cycle staff to resolve billing issues.
• Communicate professionally with insurance representatives, patients, and colleagues.
• Provide feedback to management regarding recurring payer issues or process improvements.

Payer Relations & Compliance

• Serve as the liaison between providers and insurance payers during the credentialing process.
• Monitor and interpret payer requirements, policies, and updates to ensure compliance.
• Resolve issues and discrepancies related to credentialing, enrollment, and network participation.
• Ensure credentialing practices meet all regulatory standards, including NCQA, CMS, and HIPAA.

Documentation & Tracking

• Maintain credentialing logs, spreadsheets, and databases to track application status, expiration dates, and deadlines.
• Audit credentialing files to ensure completeness and accuracy.
• Prepare reports for management on credentialing activities, pending applications, and compliance status.

Requirements

Qualifications

Education & Experience

• High school diploma or equivalent required; associate or bachelor’s degree in healthcare administration, business, or related field preferred. Certification in medical billing/coding (CPB, CPC, or equivalent) is a plus.
• Minimum 2 years of experience in medical credentialing and/or billing, preferably across multiple payers.
• Strong working knowledge of CAQH ProView, NPPES, PECOS, Availity, payer portals, and EHR/billing software.
• Proven track record of accurate claim submission, denial resolution, and maintaining compliance with payer requirements.
• Excellent attention to detail and accuracy.
• Strong organizational, time-management, and problem-solving skills.
• Effective communication skills, both written and verbal.
• Ability to manage multiple projects and deadlines simultaneously.
• Proficiency in credentialing/billing software.
• Strong understanding of CPT, ICD-10, and HCPCS coding.

Work Environment & Conditions

• This role is remote.
• Standard business hours, Monday–Friday.
• Requires sitting for extended periods and extensive use of computer systems.

Performance Metrics

• Timeliness of credentialing, re-credentialing, and claim submissions.
• Accuracy of credentialing files, claims, and documentation.
• Successful provider enrollment and claim reimbursement with minimal delays or denials.
• Compliance with payer and regulatory requirements.

Thrivelab Co. is an Equal Opportunity Employer and does not discriminate on the basis of race or ethnicity, religion, sex, national origin, age, veteran disability or genetic information or any other reason prohibited by law in employment.