Credentialing Specialist

Essential Duties and Responsibilities

• Coordinate TMHP and Medicare (MCR) revalidation processes, ensuring accuracy and compliance with deadlines
• Set up payor sites for eligibility, claim filing, claim status, ERA, EFT, and appeals
• Establish and maintain group accounts for multi-providers
• Maintain and update provider licenses and insurance addresses
• Prepare enrollment applications for all health plans, including Medicare and Medicaid
• Complete and distribute W-9 forms
• Demonstrate problem-solving and customer service skills
• Ability to understand, analyze, and interpret complex documents

Knowledge and Experience

• High school diploma/GED required
• Minimum of 2 years of provider enrollment experience preferred, including TMHP and Medicare revalidation
• Ability to distinguish and explain an EFT, ERA, EOB, COB, and “pay to” address
• Ability to read and understand payor applications and how payors work
• Knowledge of federal and state insurance laws and their interpretation as appropriate
• Knowledge of insurance claim processing, third-party reimbursement, and revalidation processes
• Ability to work within a deadline-intense environment prioritizing workflow as needed
• Must be able to communicate clearly and professionally, verbally and in writing