Utilization coordinator vs credentialing specialist

Differences between utilization coordinator and credentialing specialist duties and responsibilities

Utilization coordinator example responsibilities.

• Manage and coordinate authorization of denial letters and request for appeals with all levels of services.
• Manage and coordinate the workload of the release team members and are responsible for organizing and hosting all production release windows.
• Perform accurate verification of eligibility and benefits as well as advanced application of CPT, ICD-9 and ICD-10 codes.
• Assign accurate ICD-9 and CPT codes to request services for referral and authorization processing.
• Claim adjudication for assign HMO members.
• Provide orientation to pre-certification process for HMO, PPO, and POS members.
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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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