PATH BEHAVIORAL HEALTHCARE

JOB DESCRIPTION

TITLE: Heathcare Authorization/Credentialing Specialist:  West Virginia 

REPORTS TO: CRO (Chief Revenue Officer)

WORK AREA: Home Office (West Virginia)

SUMMARY: Manages insurance authorization processes for behavioral health services,

ensuring proper approval and documentation for client treatments. The candidate will need to

have experience with out of network commercial insurance, single case agreements,

authorization follow-through with VACCN, as well as West Viriginia Medicaid authorization

requirements. The candidate will also be responsible for the timely credentialing of all staff, this

position ensures compliance with licenses and certifications, maintaining close collaborations

across departments like Billing and Operations. They actively address process improvements,

support audit processes, and uphold the highest standards in HIPAA guidelines and company

policies. Their overarching goal is to ensure both new and active staff members are always

compliant, reflecting the organization's commitment to excellence and integrity.

BLOODBORNE PATHOGEN CATEGORY I: Tasks with actual blood/body fluid exposure are not

included in this position’s duties as the job requires therapeutic counseling only.

PRIMARY JOB DUTIES:

• Review medical documentation and insurance requirements

• Submit authorization requests to insurance providers

• Verify patient insurance coverage and benefits

• Track and follow up on authorization status

• Communicate with healthcare providers and insurance companies

• Resolve authorization denials and appeal processes

• Ensure swift credentialing for all new hires, accurately reflecting any changes.

• Monitor the credentialing status of both new and active staff, ensuring providers maintain valid

credentials, such as licenses and certifications, to practice legally within their specialization.

• Actively track upcoming expirations for licenses, certificates, educational qualifications, and CAQH

•Collaborate with the CCO, COO, and Operations to meet all compliance requirements, ensuring site

credentials and licenses are current and addressing any potential issues promptly

•Provide regular updates to Operations and staff on current credentialing statuses through both routine

reports and immediate notifications

•Work closely with the Billing team to maintain open communication with insurance companies about

contract changes and policy updates

• Identify areas for process improvement and coordinate with relevant departments for streamlined

implementation

• Oversee general training and manage updates within CareLogic

• Conduct employee status audits and update IDs and employee information in CareLogic

• Collaborate across departments to resolve any credentialing discrepancies

• Support audit processes, providing essential assistance and information when required.

• Stay informed on best practices for Medicaid provider credentialing as well as Commercial Payers as

we add them to our portfolio, ensuring the agency's compliance and efficiency in coordination with

Operations.

• Uphold strict adherence to HIPAA guidelines, confidentiality protocols, billing and coding standards,

and company policies.

• Take on additional tasks or responsibilities as assigned by the Operations Team and CRO.

QUALIFICATIONS

Education

• Associate's or Bachelor's degree in healthcare administration

Experience/Skills

• Knowledge of medical terminology

• Understanding of insurance policies and procedures, including electronic claims processing and

insurance verifications.

• Minimum of 3 years of experience in medical billing or credentialing, preferably within a behavioral

healthcare setting.

• Proven experience overseeing a team, with a focus on optimizing productivity and performance.

• Familiarity with billing software and electronic medical records (EMRs).

• Strong understanding of medical coding and billing processes.

• Comprehensive knowledge of healthcare accreditation and licensing standards.

•Experience with payroll processes and related software.

•Solid understanding of insurance procedures, contracts, and provider credentialing processes.

• Strong communication skills

• Attention to detail

• Proficiency in healthcare software and electronic medical record systems, including medical billing

software

•HIPPA compliance knowledge

Desired Skills

• Medical coding certification

• 2-3 years healthcare authorization experience

• Problem-solving abilities

Physical Effort: This position requires the ability to work under stressful conditions and to work

irregular hours. Requires sitting for extended periods of time, viewing computer monitors, and

keyboarding.

Communication Skills: must possess excellent verbal and written communication skills in order to

communicate professionally via telephone and in writing. Strong grammar and writing skills are

crucial for clear and concise communication with clients, colleagues, and other healthcare

professionals.

Interpersonal Skills: The successful candidate must demonstrate the ability to interact and assist in a

friendly, compassionate, and professional manner with colleagues, providers, clients, and their

families, as they represent both themselves and Path Behavioral Healthcare.

Essential Technical/Motor Skills: Candidates must achieve competency in the Electronic Health

Record (EHR) program, telemedicine services, and any additional software programs utilized by the

company, ensuring efficient access and updating of client information. The role requires fine

dexterity, adept handling, and proficient gripping abilities to perform various tasks.

Background: The candidate must pass all federal and state background checks, and their educational

and work history will be confirmed in compliance with company policies.