Credentialing, Registration & Prior Authorization Specialist

Credentialing, Registration & Prior Authorization Specialist We are seeking a highly organized, detail-oriented, and customer-focused Credentialing, Registration & Prior Authorization Specialist to join our growing behavioral health team. This multifaceted role is responsible for ensuring agency and provider credentialing compliance, coordinating client registration and scheduling, verifying insurance benefits, and managing prior authorizations for medications and services. The ideal candidate possesses strong administrative and critical thinking skills, a thorough understanding of healthcare insurance processes, and the ability to thrive in a fast-paced outpatient behavioral health environment. Essential Duties and Responsibilities Credentialing Coordinate and oversee the credentialing and recredentialing process for medical, mental health, and allied healthcare providers. Review practitioner applications and supporting documentation to ensure eligibility and compliance. Conduct primary source verification, background investigations, and credential file audits. Identify discrepancies, investigate issues, and ensure timely resolution. Prepare and maintain credentialing files as directed by agency leadership. Monitor expiring licenses, certifications, registrations, and insurance coverage, initiating renewals as necessary. Maintain compliance with applicable regulatory and accreditation standards, including CMS, Joint Commission, NCQA, URAC, federal and state regulations, and delegated payer contracts. Submit and retrieve National Practitioner Data Bank (NPDB) reports. Coordinate credentialing for new agency programs and services. Collaborate with Billing, Human Resources, and agency leadership to resolve credentialing and compliance issues. Assist with delegated credentialing audits and conduct internal quality reviews. Support HR compliance and risk management activities related to provider credentialing. Maintain credentialing databases and generate required reports. Assist with agency compliance initiatives, including accreditation and regulatory requirements. Registration and Intake Answer incoming intake and registration calls in a professional and compassionate manner. Collect demographic, insurance, and clinical information from prospective and returning clients. Screen callers and assess needs to schedule appointments with appropriate providers. Verify insurance eligibility and benefits through electronic and telephonic methods. Process referrals and maintain referral tracking systems. Manage appointment scheduling and client correspondence. Return voicemails and respond to intake inquiries promptly throughout the day. Monitor referrals received via fax and designated email accounts. Route calls appropriately and relay messages to staff. Maintain accurate and timely documentation within the electronic medical record (EMR). Prior Authorizations Serve as an administrative liaison between patients, providers, pharmacies, and insurance companies. Verify insurance eligibility, benefits, formulary requirements, and prior authorization needs. Prepare and submit prior authorization requests with accurate clinical documentation, diagnosis codes, and supporting records. Track pending authorization requests and conduct timely follow-up with insurance carriers. Monitor authorization statuses to ensure continuity of patient care. Manage denied requests by reviewing payer requirements, gathering additional documentation, and initiating appeals. Assist with prior authorizations for Bureau of Workers' Compensation and other specialty programs. Qualifications Required Knowledge and Skills Knowledge of behavioral health and substance use disorder terminology. Understanding of healthcare insurance plans, eligibility verification, and prior authorization processes. Strong customer service and communication skills. Ability to appropriately manage urgent or crisis-related calls. Exceptional attention to detail and organizational abilities. Strong critical thinking and problem-solving skills. Ability to work independently and collaboratively in a fast-paced environment. Proficiency with electronic medical records (EMR), Microsoft Office Suite, including Excel and Teams. Commitment to providing exceptional service to clients and supporting agency operations. Experience Previous experience in provider credentialing, medical office administration, behavioral health, managed care, or healthcare registration preferred. Experience with insurance verification and prior authorizations strongly preferred. Knowledge of medical terminology, credentialing standards, and healthcare regulations. Experience using credentialing software and provider databases preferred. Preferred Attributes Self-motivated and highly dependable. Professional and compassionate demeanor. Strong multitasking and time management skills. Ability to maintain confidentiality and exercise sound judgment. Adaptable and eager to contribute to a collaborative team environment.

Benefits:

401(k) 401(k) matching Dental insurance Flexible spending account Health insurance Life insurance Paid time off Vision insurance Ability to

Relocate:

Garfield Heights, OH 44125: Relocate before starting work (Required)

Work Location:

In person