Credentialing specialist vs referral specialist

Differences between credentialing specialist and referral specialist duties and responsibilities

Credentialing specialist example responsibilities.

• Establish rapport with all PCP offices, hospital personnel, and manage care representatives.
• Manage and administer the programs CME accredit education programs/Conferences.
• Ensure enrollment and participation with all organization contract managed care plans and perform Medicaid/Medicare provider enrollment.
• Process and manage all requests and applications for CME certification and supervise activities relate to credentialing process.
• Perform spot claims audits to ensure CMS compliance with ICD-9, HCPCS, CPT, and other requirements.
• Maintain and track data for OPPE and FPPE according to hospital policy and regulatory requirements.
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Referral specialist example responsibilities.

• Manage assignments of paying medical bills limit in depth that include organizing and researching regulations as pertain to veterans eligibility.
• Interview patients, evaluate eligibility, collect co-pays, deductibles, including, but not limit to insurance verification.
• Input HIPAA information, call physician offices to verify testing, collect copay's and deductibles.
• Arrange for debt repayments or establish repayment schedules and send out insurance claims with the correct ICD-9 and CPT codes.
• Research referrals and either deny or approve based on information obtain and appropriately identify diagnosis (CPT and ICD-9 coding).
• Maintain confidentiality by following all applicable HIPAA regulations.
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