Job Description

**SUMMARY : **A Credentialing and Patient Accounts Specialist verifies healthcare provider credentials, manages enrollment with payers, tracks license and certification expirations, and supports patient account activities to ensure compliance and smooth billing operations. The Credentialing and Patient Accounts Specialist is responsible for managing the credentialing of healthcare providers, ensuring all necessary licenses, certifications, and qualifications are valid and up to date. Additionally, this role oversees patient account processes related to provider enrollment, insurance verification, and coordination with billing teams to prevent claim delays. This position is crucial for maintaining regulatory compliance, accurate provider records, and seamless revenue cycle operations.

ESSENTIAL FUNCTIONS :

• Provider Credentialing & Verification
  • o Collect, verify, and maintain provider credentials, licenses, certifications, and other required documentation
  • o Perform primary source verification for education, medical training, licensure, DEA registrations, and malpractice coverage
  • o Submit initial and Recredentialing applications to insurance payers including Medicare, Medicaid, and commercial plans
  • o Monitor expiration dates for licenses, certifications, and insurance, initiating renewals as needed
  • o Maintain organized, audit-ready credentialing files and prepare reports for committees or leadership
• Patient Accounts Support
  • o Communicate provider enrollment status with revenue cycle management (RCM), billing teams, and leadership to avoid claim delays
  • o Troubleshoot enrollment rejections, data mismatches, or payer requests to ensure timely processing
  • o Maintain accurate records of provider participation and insurance plan affiliations in credentialing databases.
• Compliance & Regulatory Duties
  • o Ensure all credentialing and patient account processes comply with NCQA, The Joint Commission, CMS, and state regulatory standards
  • o Stay current with federal and state regulations related to provider credentials and insurance.
  • o Participate in audits and provide data or documentation as required.
  • o Develop and enhance internal credentialing and patient account processes
• Communication & Coordination
  • o Coordinate between internal departments, providers, and external agencies to collect necessary information and resolve issues
  • o Respond to inquiries from providers or payers regarding credentialing and enrollment processes.
  • o Provide guidance or training to other staff on credentialing workflows, software use, and documentation standards.

Qualifications

Education :

Associate’s or Bachelor’s degree in Healthcare Administration, Business, or a related field preferred; comparable experience may be considered.

Related Work Experience:

2-3 years in credentialing, provider enrollment, or healthcare administrative support; experience with patient accounts or billing is a plus

Licensure/Certification:

CPCS (Certified Provider Credentialing Specialist) preferred; CPMSM preferred

Specialized Knowledge and Skills:

Proficiency with credentialing software and databases (e.g., CAQH, PECOS, NPPES, VerityStream, Cactus, IntelliSoft)

Familiarity with Microsoft Office, particularly Excel and Word

Exceptional attention to detail and accuracy

Strong organizational and time-management abilities

Effective communication skills to liaise with providers, payers, and internal Teams. Ability to manage confidential information and multi-task under pressure

Additional Information

All your information will be kept confidential according to EEO guidelines.

La Rabida is a place unlike any other. We understand the needs of families with children dealing with the most serious or complicated of conditions. With teams of the best healthcare providers in Chicago, we give continuous, comprehensive care, education, and support, helping families face their unique obstacles head-on.

La Rabida Children’s Hospital is very proud to be an Equal Employment Opportunity Employer.