Credentialing and Reimbursement Manager

This position is responsible for assisting with the overall management and leadership of the Credentialing and Reimbursement Department. This position will ensure accurate and timely credentialing, investigate payer setup issues, and is responsible for the training and development of the team.

REPORTS TO/SUPERVISES

The Credentialing and Reimbursement Manager reports directly to the Director of Revenue Cycle Management and works collaboratively with other Emergicon personnel in all departments. This position is responsible for the supervision of all Credentialing and Reimbursement staff.

ESSENTIAL DUTIES AND RESPONSIBILITIES

• Ensure timely, efficient, and accurate credentialing and reimbursement of all clients

• Develop credentialing and reimbursement workflows, protocols, and procedures

• Identify, and act on, opportunities to improve credentialing and reimbursement activities

• Develop and maintain processes making provider statuses readily available to Operations

• Monitor and review payer set up and establish action plans to resolve issues

• Track license and certification expirations for all providers and ensures timely renewals

• Monitor daily communications with Medicare, Medicaid, and commercial insurance companies to ensure updates are completed timely

• Monitor and track Medicare and Medicaid revalidations

• Maximize ERAs and EFTs to ensure efficiency

• Assist in onboarding of new clients - Money Flow, Banking, EOM funds

• Manage missing EOB log and Commercial Banking Projects

• Monitor and stay informed of industry trends and legislative changes to ensure compliance and best practices.

• Monitor Freshdesk tickets for reimbursement and credentialing

• Train new employees, monitor progress, and offer consistent guidance

• Ensure team adherence to company policies and procedures 

• Model and consistently reinforce adherence to Emergicon’s Core Values 

• Other job-related duties as assigned 

EDUCATION AND EXPERIENCE

• Associate’s degree or higher in healthcare management, business administration, or a related field preferred.

• Minimum of three (3) years of experience in credentialing and reimbursement, specifically in Texas Medicaid and Medicare Part B, with a strong understanding of payer processes and systems.

• Extensive experience working with credentialing and reimbursement platforms and tools including CMS, NPPES, DSHS, TMHP, PALMETTO GBA, PECOS, Dept of Labor, SAM, and NAVINET.

• Proven track record of managing Texas Medicaid, Medicare Part B, and commercial payer EDI/ERA/EFT setup, ensuring seamless payer interactions and timely updates.

• At least three (3) years of direct experience in the setup and management of payer portals, EDI/ERA/EFT transactions, and working with both Medicare and Medicaid, in addition to commercial insurance processes.

• Minimum of two (2) years of management experience with a demonstrated ability to lead a team, set performance targets, and motivate and develop team members to achieve department goals.

• Experience in identifying and resolving payer setup issues and optimizing processes for credentialing and reimbursement.

• Strong understanding of industry trends and compliance requirements, ensuring adherence to legislative changes and best practices in credentialing and reimbursement activities.

KNOWLEDGE, SKILLS, AND ABILITIES

• Strong understanding of federal and state insurance laws and their interpretation, particularly related to Medicaid, Medicare, and commercial insurance.

• Intermediate proficiency in Microsoft Excel, with the ability to analyze and manage data related to credentialing and reimbursement processes.

• Demonstrated problem-solving skills with a focus on resolving payer setup issues and addressing challenges in credentialing and reimbursement.

• Excellent communication and customer service skills, ensuring clear, professional interactions with insurance providers, clients, and internal teams.

• Highly detail-oriented with exceptional organizational skills and the ability to prioritize tasks and manage deadlines efficiently in a high-pressure, deadline-driven environment.

• Adaptability to thrive in a fast-paced environment and quickly learn new systems or processes related to credentialing and reimbursement.

• Proven leadership skills with experience coaching, training, and managing teams to meet performance goals, while fostering a collaborative and supportive work environment.