This position supports the Agency’s delivery of community mental health services by coordinating credentialing, recredentialing, and payer enrollment activities for clinical mental health staff and medical providers. The Credentialing Specialist maintains accurate provider and payer records in the Agency’s electronic systems and works closely with clinical, administrative, and billing staff to ensure services can be billed and reimbursed appropriately (including Vermont Title XIX Medicaid and commercial insurers). The position is responsible for accurate and timely patient fee billing across selfpay, commercial insurance, Medicaid, and Medicare payors, ensuring that all services are billed, processed, and collected in accordance with payer requirements and organizational policies. The role includes verifying demographic and insurance information, preparing and submitting claims, generating patient statements, posting payments, and following up on outstanding balances and denials. The Billing Clerk works closely with clinical, front office, and finance staff, provides clear and respectful customer service to patients and payors, and maintains strict confidentiality and compliance with HIPAA and all applicable regulations.

Duties & Responsibilities

The following duties and responsibilities reflect the essential functions of the position, but do not restrict the assignment of additional tasks. Reasonable accommodations may be granted to support individuals with disabilities in performing the position’s essential functions.

Credentialing Specific Tasks:

1. Coordinate initial credentialing, recredentialing, and payer enrollment for Agency clinical staff and medical providers, including tracking required documentation and deadlines.
2. Maintain organized, accurate, and audit-ready credentialing files (electronic and/or paper) for providers and associated payer correspondence.
3. Verify and monitor credentialing prerequisites (as applicable to role), such as licensure status, expirations/renewals, and other required documentation; communicate upcoming expirations to providers and leadership.
4. Provide credentialing/contracting support to program administrative teams as needed.
5. Maintain provider demographic and enrollment-related information in the Agency’s electronic medical record/billing system(s) (e.g., MyAvatar), supporting accurate downstream billing.
6. Maintain consistent billing workflows by ensuring provider/payer information is current and aligned to billing requirements (e.g., payer participation, effective dates, service location details, and related set-ups as needed).
7. Research and resolve reimbursement issues and denials when credentialing/enrollment status, provider records, billing codes, or payer setup may be a contributing factor.
8. Support insurance-related administrative processes connected to service access and billing, including assisting with verifying insurance/Medicaid eligibility for scheduled services as assigned.
9. Produce and distribute credentialing and billing-support reports as needed (e.g., upcoming expirations, enrollment status lists, reconciliation/support logs).

Billing Specific Tasks

1. Collect, verify, and enter patient demographic, insurance, and guarantor information into the billing system for selfpay, commercial, Medicaid, and Medicare accounts.
2. Generate and submit accurate claims (electronic and paper) to commercial insurance, Medicaid, and Medicare, following each payer’s specific billing rules and formats.
3. Produce and send patient statements for selfpay balances, including deductibles, copays, and coinsurance, and arrange payment plans as authorized.
4. Verify patient insurance eligibility and benefits, including coordination of benefits and coverage limits, prior to or shortly after service.
5. Obtain, document, and track prior authorizations or precertifications required by commercial insurers, Medicaid, and Medicare.
6. Review charges, coding, and documentation to ensure all services are billed with appropriate CPT/HCPCS and ICD10 codes and required modifiers before claim submission.
7. Monitor electronic claim edits and clearinghouse rejections; correct errors and resubmit claims promptly.
8. Post and reconcile payments, remittances, and explanations of benefits (EOB/ERA) from patients and all payers, ensuring accurate allocation to accounts.
9. Identify, research, and resolve underpayments, denials, and nonpaid claims, including following up with payers, correcting claims, and submitting appeals as appropriate.
10. Follow up on outstanding patient and insurance balances, including phone outreach, letters, and coordination with any external collection resources per policy.
11. Maintain accurate, uptodate account notes and billing records, including documentation of contacts, authorizations, payment arrangements, and followup actions.
12. Respond to patient questions regarding statements, insurance coverage, and payment options, providing clear explanations and escalating complex issues when needed.
13. Communicate with commercial insurers, Medicaid, Medicare, and other thirdparty payors to clarify coverage, resolve claim issues, and obtain needed information.
14. Protect patient confidentiality and comply with HIPAA and organizational privacy and security policies in all billing activities.
15. Assist with producing routine billing reports (e.g., aging, denials, bad debt, and payer mix) and provide information to support internal audits and reconciliations.

Education & Experience

• Education: High school diploma required; Associate’s Degree preferred.
• Experience: Prior experience in a medical/behavioral health administrative setting strongly preferred. Experience with electronic medical records and computerized billing systems preferred. Familiarity with Vermont Title XIX Medicaid processes/regulations and third-party/commercial insurance billing support is highly desirable (as reflected in Agency billing operations).
• Technology: Proficiency with Microsoft Excel, Word, and Outlook preferred; ability to learn and use the Agency’s EMR/billing systems (e.g., MyAvatar).

Knowledge & Competencies

• Ability to maintain accurate records and manage administrative workflows, multiple tasks, and competing deadlines.
• Strong verbal and written communication skills, including the ability to explain documentation requirements and resolve issues with internal and external partners.
• Detail-oriented problem-solving skills (e.g., tracking missing items, correcting record discrepancies, supporting denial resolution).
• Proficiency in applying technology to work processes, including data entry, reporting, and document management.
• Ability to build and maintain strong, productive, professional relationships with internal and external partners.

Working Conditions

This position is primarily office-based and computer-focused but can be done via remote or hybrid work.

Physical Requirements

• Frequently required to remain in a stationary position for extended periods of time.
• Constant operation of a computer, keyboard, mouse, and other office devices.
• Active participation in training sessions, presentations, and meetings.
• Occasionally may be required to work extended hours to meet time-sensitive credentialing/ enrollment or billing deadlines.