Credentials Staff Specialist at Conquest Healthcare | Torre
Credentials Staff Specialist
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Conquest Healthcare

Credentials Staff Specialist

Conquest Healthcare
Posted by
adolphine raymond
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You'll ensure vital healthcare access and financial integrity through meticulous compliance and credentialing.
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Full-time

Legal agreement: Employment

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Posted 27 days ago

Requirements and responsibilities

Credentialing specialists ensure that doctors are legally and contractually eligible to receive payment from third-party payers. Payer Enrollment: - Managing applications for Medicare (PECOS), Medicaid, and commercial insurance plans (e.g., Blue Cross, Aetna) to link the provider's NPI to the billing entity. Primary Source Verification: - Confirming the authenticity of medical licenses, board certifications, DEA registrations, and education directly with the issuing boards. CAQH Management: - Maintaining and updating the Council for Affordable Quality Healthcare (CAQH) profiles, which most commercial payers use as a centralized database for provider data. Revalidation & Expiration Tracking: - Monitoring the "end dates" for licenses and certifications. - If a DEA license or state medical license expires, the billing department must stop submitting claims immediately to avoid "unauthorized provider" denials. Key Responsibilities for Compliance Staff: - Compliance officers focus on the legal integrity of the billing process, protecting the practice from audits, fines, and fraud allegations. Coding Audits: - Reviewing CPT and ICD-10 codes assigned by billers to ensure they match the clinical documentation provided by the doctor. Regulatory Monitoring: - Staying current with CMS (Centers for Medicare & Medicaid Services) updates and OIG (Office of Inspector General) work plans. HIPAA Oversight: - Ensuring that patient data handled during the billing and collection process remains secure and private. Excluded Provider Checks: - Periodically checking the OIG Exclusion List (LEIE) to ensure no staff member or physician has been banned from participating in federal healthcare programs.

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