Job Description – AR Appeals & Credentialing Specialist

Job Description: AR Appeals & Credentialing Specialist

Position Title

AR Appeals & Credentialing Specialist

Department

Revenue Cycle Management (RCM) / Medical Billing / Provider Enrollment

Reporting To

AR Manager / RCM Manager / Credentialing Manager

Location

[Location / Remote / Hybrid]

Employment Type

Full time

Experience

2–5 years of relevant experience in US Healthcare RCM, AR follow-up, denials/appeals, and/or provider credentialing.

Position Summary

The AR Appeals & Credentialing Specialist is responsible for managing outstanding accounts receivable, researching claim denials and underpayments, preparing and submitting payer appeals, and supporting provider credentialing and enrollment activities.

The role requires strong knowledge of the US healthcare revenue cycle, insurance payer requirements, claims processing, denial management, provider enrollment, credentialing, and documentation standards.

The specialist will work closely with billing, coding, payment posting, clinical, provider enrollment, and payer teams to resolve unpaid or incorrectly paid claims and ensure providers are properly credentialed and enrolled with insurance plans.

The ideal candidate should have strong analytical, communication, documentation, follow-up, and problem-solving skills, with the ability to manage multiple payer requirements and deadlines.

- Job Description for AR Appeals

Key Responsibilities

1. Accounts Receivable (AR) Management

- Review and analyze outstanding insurance AR across assigned payer accounts.
- Work assigned AR reports, aging reports, work queues, and payer-specific inventories.
- Prioritize accounts based on aging, dollar value, denial reason, timely filing limits, and payer requirements.
- Perform detailed claim-level investigation to determine the reason for non-payment.
- Verify claim status through payer portals, clearinghouses, payer websites, IVR systems, and payer representatives.
- Contact insurance companies to obtain claim status, payment information, denial details, and required corrective actions.
- Identify claims that require rebilling, corrected claims, reconsideration, appeal, medical records, or additional documentation.
- Follow up on unpaid, partially paid, rejected, denied, and underpaid claims.
- Maintain accurate documentation of every follow-up activity and payer interaction.
- Escalate unresolved or high-dollar accounts according to organizational procedures.
- Monitor AR aging and ensure timely follow-up before payer filing and appeal deadlines expire.

2. Denial Management

- Review Explanation of Benefits (EOBs), Electronic Remittance Advice (ERA), denial letters, and payer correspondence.
- Identify root causes of claim denials and determine the appropriate resolution.
- Handle denials related to:
- Authorization/referral
- Medical necessity
- Eligibility
- Coverage
- Coding
- Bundling
- Duplicate claims
- Timely filing
- Provider credentialing
- Provider enrollment
- Non-covered services
- Incorrect payer
- Coordination of Benefits (COB)
- Modifier issues
- Documentation requirements
- Out-of-network status
- Claim submission errors
- Contractual/payment discrepancies
- Categorize denials accurately for reporting and trend analysis.
- Identify recurring denial patterns and communicate root causes to management and relevant departments.
- Recommend corrective actions to prevent repeat denials.

3. Appeals and Reconsiderations

- Review denied and underpaid claims to determine whether an appeal or reconsideration is appropriate.
- Research payer-specific appeal guidelines, filing limits, required forms, and documentation requirements.
- Prepare professional and fact-based appeal letters.
- Compile supporting documentation, including:
- Medical records
- Clinical notes
- EOBs/ERAs
- Claim forms
- Authorization documentation
- Referral documentation
- Provider records
- Credentialing/enrollment documentation
- Payer correspondence
- Coding documentation
- Proof of timely filing
- Proof of claim submission
- Submit first-level and, where applicable, subsequent-level appeals within payer deadlines.
- Track appeal submission dates, reference numbers, deadlines, and outcomes.
- Follow up with payers on pending appeals.
- Review appeal determinations and identify additional escalation opportunities.
- Maintain an organized appeal inventory and supporting documentation.




- Escalate complex or high-value appeals to management or clinical/coding teams when necessary.
- Ensure appeals are supported by accurate documentation and applicable payer requirements.

4. Underpayment Analysis

- Compare payer reimbursement against contracted or expected reimbursement where contract information is available.
- Identify potential underpayments and incorrect contractual adjustments.
- Research payer payment policies and contract terms.
- Prepare reconsiderations or appeals for underpaid claims when appropriate.
- Document payment discrepancies and communicate recurring issues to management.
- Coordinate with contracting or provider relations teams for unresolved reimbursement issues.

- Job description for Credentialing Specialist

1. Provider Credentialing & Enrollment

- Support credentialing and enrollment of physicians, providers, and other healthcare professionals with commercial and government payers.
- Complete and maintain provider enrollment applications accurately and within required timelines.
- Work with payer portals and enrollment systems to submit and monitor applications.
- Maintain provider demographic and practice information, including:
- Provider name
- NPI
- Taxonomy
- Specialty
- Practice address
- Mailing address
- Billing address
- Phone/fax information
- Tax Identification Number (TIN)
- Group affiliation
- Maintain and update provider information in applicable credentialing/enrollment systems.
- Track enrollment status from application submission through approval.
- Follow up with payers regarding pending, incomplete, rejected, or returned applications.
- Respond to payer requests for additional documentation.
- Maintain accurate records of enrollment effective dates and revalidation requirements.

2. Credentialing Documentation

Coordinate collection, verification, and maintenance of provider credentialing documents, such as:

- CAQH profile information
- NPI documentation
- State medical/professional licenses
- DEA certificates, where applicable
- Board certifications
- Professional liability/malpractice insurance
- Education and training documentation
- Work history
- Hospital privileges, where applicable
- W-9 documentation
- Provider agreements
- Taxonomy information
- Medicare/Medicaid enrollment information
- Payer-specific enrollment forms
- Other payer-required documentation

Ensure documents are current and submitted according to payer requirements.

3. CAQH Management

- Maintain and update provider information in CAQH.
- Ensure required provider documentation is current.
- Monitor CAQH attestation and re-attestation requirements.
- Identify missing or expired documents.
- Coordinate with providers and internal teams to obtain updated documentation.
- Resolve discrepancies between CAQH, payer records, NPI information, and internal systems.

4. Payer Enrollment & Revalidation

- Process new provider enrollment applications.
- Process provider additions to existing group contracts.
- Handle provider demographic updates and practice-location changes.
- Support Medicare, Medicaid, and commercial payer enrollment activities as applicable.
- Monitor revalidation and recredentialing deadlines.
- Track payer effective dates and ensure billing begins only according to applicable enrollment requirements.
- Investigate claims denied because of provider enrollment or credentialing issues.
- Coordinate with payer representatives to resolve enrollment-related claim problems.

5. Credentialing-Related AR Resolution

- Investigate AR accounts denied due to:
- Provider not enrolled
- Provider not credentialed
- Incorrect provider participation status
- Incorrect billing/rendering provider information
- Missing payer enrollment
- Incorrect effective date
- Provider demographic mismatch
- Determine whether the issue can be resolved through corrected claims, reconsideration, appeal, enrollment correction, or payer escalation.
- Coordinate with credentialing and billing teams to prevent additional claims from being affected.




- Track credentialing-related denial trends and report recurring issues.

6. Payer Communication

- Communicate professionally with payer representatives through phone, email, portals, and written correspondence.
- Obtain and document:
- Claim status
- Denial reason
- Appeal requirements
- Filing deadlines
- Reference numbers
- Payer representative information
- Enrollment status
- Effective dates
- Required documentation
- Escalate unresolved payer issues through appropriate channels.
- Maintain payer-specific knowledge and update internal reference materials as requirements change.

7. Documentation & Reporting

- Maintain complete and accurate notes for all AR, appeal, and credentialing activities.
- Update billing/RCM/credentialing systems on a timely basis.
- Maintain trackers for:
- Outstanding AR
- Appeals
- Reconsiderations
- Credentialing applications
- Enrollment applications
- Revalidations
- Payer follow-ups
- Provider documentation
- Prepare daily, weekly, and monthly productivity reports as required.
- Report significant payer issues, aging concerns, and credentialing delays to management.
- Ensure documentation is audit-ready.

12. Compliance & Quality

- Follow HIPAA and applicable healthcare privacy and security requirements.
- Maintain confidentiality of patient and provider information.
- Follow company policies, payer guidelines, and documented RCM procedures.
- Ensure claims and appeals contain accurate and appropriate information.
- Avoid submitting unsupported or inaccurate appeal information.
- Maintain high accuracy in provider enrollment and credentialing applications.
- Participate in internal quality audits and corrective-action initiatives.

Key Performance Indicators (KPIs)

Performance may be measured using the following metrics:

AR & Follow-Up

- AR dollars worked
- Number of accounts worked
- Touches/follow-ups completed
- Collection amount
- Aging reduction
- Resolution rate
- Average days to resolution

Denials & Appeals

- Denial resolution rate
- Appeal submission turnaround time
- Appeal success/recovery rate
- Appeal inventory aging
- Dollar value recovered
- First-pass appeal resolution
- Timely submission percentage

Credentialing

- Number of applications processed
- Application accuracy rate
- Enrollment turnaround time
- Provider enrollment completion rate
- Revalidation completion rate
- CAQH accuracy/completion
- Payer follow-up turnaround
- Credentialing-related denial reduction

Quality

- Documentation accuracy
- Audit score
- Compliance with payer deadlines
- Productivity
- Error rate

Required Skills

- Strong knowledge of US healthcare revenue cycle management.
- Understanding of medical claims and payer processing.
- Strong AR follow-up and denial management skills.
- Experience preparing insurance appeals and reconsiderations.
- Knowledge of payer-specific appeal requirements.
- Understanding of provider credentialing and enrollment processes.
- Knowledge of CAQH, NPI, Medicare/Medicaid, and commercial payer enrollment processes.
- Strong analytical and problem-solving ability.
- Excellent written and verbal communication.
- Strong attention to detail.
- Ability to interpret EOBs, ERAs, denial codes, and payer correspondence.
- Strong documentation and organizational skills.
- Ability to manage multiple priorities and deadlines.
- Proficiency with Microsoft Excel and healthcare/RCM software.
- Ability to work independently and meet productivity targets.

Preferred Knowledge

Candidates with experience in the following areas will be preferred:

- US physician billing
- Hospital or facility billing
- Professional claims
- Institutional claims
- Medicare
- Medicaid
- Commercial insurance
- Medicare Advantage
- Managed Care
- Workers' Compensation, where applicable
- Provider enrollment
- Credentialing
- CAQH
- PECOS
- NPPES/NPI
- Payer portals
- Clearinghouse systems
- Denial management
- Appeals and reconsiderations
- Contractual underpayment analysis

Education

Required:

- Bachelor's degree or equivalent experience preferred.

Preferred certifications/education:

- Medical Billing and Coding certification
- Certified Revenue Cycle Representative (CRCR)
- Certified Professional Coder (CPC)
- Certified Professional Biller (CPB)
- Healthcare provider credentialing/enrollment training

Relevant healthcare RCM experience may be considered in lieu of formal qualifications.

Pay: ₹10,021.09 - ₹35,802.52 per month

Benefits:

- Flexible schedule

Work Location: In person

📌 AR Appeals & Credentialing (India)
🏢 Allied HANR
📍 India