Revenue Cycle & Credentialing Specialist

Department: Revenue Cycle / Credentialing
Classification: Non-Exempt
Compensation: $19.00–$23.00 per hour
Employment Type: Full-Time

Position Summary

The Revenue Cycle & Credentialing Specialist is a shared resource between the Revenue Cycle and Credentialing teams responsible for resolving accounts receivable and claim issues that are related to provider credentialing, enrollment, payer participation, or other provider-specific billing concerns.

This position will work directly with outstanding claims and accounts receivable to identify barriers to payment, resolve issues when possible, and coordinate with the appropriate internal teams when additional action is required. The Specialist will also serve as a resource to providers regarding credentialing and enrollment questions and will review Revenue Cycle support tickets to resolve or appropriately escalate issues.

The ideal candidate is organized, detail-oriented, comfortable working across multiple departments, and able to independently investigate issues through resolution.

Essential Duties and Responsibilities

Accounts Receivable and Claims Resolution

• Work assigned accounts receivable and outstanding claims to obtain payment from insurance payers.
• Review rejected, denied, held, or unpaid claims to determine the underlying cause of nonpayment.
• Identify claims impacted by provider credentialing, payer enrollment, effective dates, network participation, provider records, or related issues.
• Follow up with insurance payers regarding claim status, credentialing-related denials, enrollment issues, and payment delays.
• Correct or coordinate correction of claim issues when appropriate and ensure claims are resubmitted or reconsidered.
• Track outstanding issues through resolution and follow up timely to maximize collections.
• Document all actions, payer communications, and next steps within applicable systems.
• Identify trends or recurring credentialing-related issues that are causing claims to remain unpaid and communicate those trends to leadership.

Credentialing Support

• Serve as a liaison between Revenue Cycle and Credentialing for provider-specific billing and enrollment concerns.
• Assist providers with credentialing, enrollment, payer participation, and related questions.
• Research provider credentialing and enrollment status when claims indicate a possible credentialing issue.
• Coordinate with the Credentialing team when updates, corrections, applications, rosters, or payer follow-up are required.
• Help ensure provider demographic, enrollment, and payer information is accurate across applicable systems.
• Assist with researching discrepancies involving provider effective dates, payer participation, locations, billing information, or enrollment status.
• Communicate credentialing updates and resolutions to providers and other internal stakeholders as appropriate.

Revenue Cycle Ticket Management

• Review tickets submitted to the Revenue Cycle department involving claims, billing, payer, or credentialing concerns.
• Research the issue and independently resolve tickets that fall within the scope of the position.
• Gather necessary information and supporting documentation before escalating unresolved issues.
• Escalate tickets to Credentialing, Revenue Cycle leadership, Operations, or other appropriate departments when additional intervention is required.
• Maintain timely and professional communication with employees and providers regarding the status and resolution of submitted tickets.
• Identify repeat ticket types and opportunities to improve processes or reduce recurring issues.

Cross-Functional Responsibilities

• Act as a communication bridge between Revenue Cycle, Credentialing, providers, and Operations.
• Participate in meetings or workgroups involving credentialing-related accounts receivable issues.
• Assist with special projects involving payer enrollment, credentialing clean-up, claims resolution, or accounts receivable.
• Maintain confidentiality of patient, provider, and organizational information in accordance with HIPAA and company policies.
• Perform other related duties as assigned.

Qualifications

Required

• High school diploma or equivalent.
• Strong organizational and problem-solving skills.
• Ability to research issues independently and follow them through resolution.
• Strong written and verbal communication skills.
• Ability to manage multiple priorities and work effectively across departments.
• Strong attention to detail and ability to maintain accurate documentation.
• Proficiency with computers and the ability to learn electronic health record, billing, payer, and credentialing systems.

Preferred

• One or more years of experience in healthcare revenue cycle, medical billing, accounts receivable, credentialing, provider enrollment, or a related healthcare administrative role.
• Experience working with insurance payers and researching claim denials or payment issues.
• Familiarity with provider credentialing, payer enrollment, CAQH, NPI information, payer portals, or provider rosters.
• Experience working in behavioral health or a multi-provider medical practice.
• Knowledge of medical claims, payer terminology, denial management, and accounts receivable processes.

Key Competencies

Successful candidates should demonstrate:

• Strong investigative and problem-solving ability
• Ownership and follow-through
• Attention to detail
• Effective communication
• Customer service orientation
• Ability to work collaboratively across departments
• Ability to prioritize high-volume workloads
• Comfort communicating with providers and insurance payers
• Ability to recognize when an issue can be resolved independently and when escalation is necessary

Performance Expectations

Success in this position will be measured by the employee's ability to:

• Reduce outstanding accounts receivable associated with credentialing and enrollment issues.
• Resolve assigned claims and tickets accurately and timely.
• Increase cash collections through effective payer follow-up and issue resolution.
• Reduce the number of credentialing-related claims that remain unresolved.
• Provide responsive and accurate support to providers.
• Appropriately escalate complex issues with sufficient documentation and research.
• Identify recurring problems and help develop solutions that prevent future claim delays.