Contracting/Credentialing and Claims Auditor



  • Responsible for all aspects of the reimbursement contract renewal lifecycle – including contract terms, rate renewals and reimbursement policies.
  • Maintain data base of all insurance plans and contract rates. Utilizing billing system, maintain contract files.
  • Ensures practice addresses are current with health plans, agencies and other entities.
  • Maintains the timelines on enrollment/credentialing schedules, communicates with providers and health plans to update as needed and maintain a strict level of confidentiality for all matters pertaining to provider credentials
  • Communicates with billing and the office managers on updates as needed and explains payer information requirements


  • Responsible for ensuring providers are credentialed, appointed, and privileged with health plans and patient care facilities. Compiles and maintains current and accurate data for all providers
  • Completes provider credentialing and re-credentialing applications; monitors applications and follows-up as needed.
  • Maintains copies of current state licenses, certifications and any other required credentialing documents for all providers. Maintains confidentiality of provider information.
  • Works with revenue cycle management to ensure credentialing issues impacting the revenue cycle process are addressed timely
  • Creates & maintains provider CAQH
  • Maintains compliance with Federal and State regulations

Claims Auditing

  • Performs random audits, target audits, and audits of claims
  • Ensures compliance with appropriate company policies, procedures, guidelines, and reporting requirements; Federal and state regulations; and timeliness of claims processing.
  • Prepares written audit reports based on findings and communicates audit findings with appropriate leadership. Review audits for training issues and provide ongoing support & training to staff
  • Identifies patterns, trends, and variances related to claims and provides feedback
  • Identifying healthcare overpayments and underpayments
  • Maintains up-to-date working knowledge on regulatory requirements associated with billing and claims processing. – Reviews Current Procedural Terminology (CPT) and Healthcare Common Procedure Coding System (HCPCS) to determine proper category for benefit code determination

Essential Qualifications

  • Education: Bachelor’s degree preferred
  • Experience: 5-7 years of experience in healthcare industry
  • Experience in compliance, credentialing, auditing and claims processing experience preferred
  • Knowledge of medical terminology, medical coding principals, billing rules and regulations Medicaid/Medicare Guidelines. In depth knowledge of UB04 and medical (1500) claim formats and requirements.
  • Strong attention to detail
  • Ability to work independently in a fast-paced environment
  • Strong organization and filing skills; ability to learn quickly
  • Excellent telephone, written and verbal communication
  • Dependable and adaptable
  • Ability to handle multiple tasks, and follow up until completion
  • Working knowledge of Microsoft Suite of products (Excel, Word, Access)
  • May be required to travel occasionally based on business needs