Eligibility and Benefits Verification (E&BV)/Credentialing Specialist

Position

• Verify Insurance:

  Confirm patient eligibility, active coverage dates, benefits, deductibles, copays, and coinsurance using online portals (like Availity/Navinet) or direct calls.

• Prior Authorizations:

  Initiate, track, and manage pre-authorizations for procedures/services.

• Data Management:

  Accurately document all verification details and update patient records in practice management/EHR systems.

• Communication:

  Liaise with patients about their financial responsibility and with insurance companies/providers.

• Compliance:

  Adhere to HIPAA and company policies

Position

• Provider Credential Verification:

  Collect, review, and verify all provider credentials, including education, training, licenses, certifications, and malpractice insurance, through primary source verification.

• Payer Enrollment:

  Process initial and re-credentialing applications for various governmental (Medicare, Medicaid) and commercial insurance networks to establish and maintain "in-network" status.

• Data Management & Record Keeping:

  Maintain accurate, up-to-date provider profiles and documentation within credentialing databases and systems such as CAQH, PECOS, and NPPES, ensuring all files are audit-ready.

• Monitoring & Renewals:

  Proactively track and monitor expiration dates for licenses, certifications, and other required documents, alerting providers and initiating the renewal process to prevent service interruptions.

• Compliance & Auditing:

  Ensure that all credentialing activities comply with the standards set by regulatory and accrediting bodies like the NCQA (National Committee for Quality Assurance) and The Joint Commission.

• Communication & Issue Resolution:

  Serve as the primary liaison between providers, insurance payers, and internal billing departments to resolve discrepancies, address inquiries, and troubleshoot any delays in the credentialing or billing process.