Insurance Credentialing Specialist

QUALITY MEDICAL IMAGING OF NEVADA•Las Vegas, NV

13h•$19 - $22

About The Position

Manage QMI’s insurance enrollments across seven states, ensuring QMI is correctly enrolled with each payer, remains current with renewals, and has the electronic connections needed for claims and payments. After the credentialing process is stabilized, assist with patient insurance verification and authorization when claims have discrepancies or eligibility issues. The role handles payer enrollment and renewals, electronic claim and payment setup, portal access, tracking and follow-up, enrollment-related billing problems, payer contacts, site surveys, and organizational licensing or certification needs. It also supports Intake and Billing with insurance verification and prior authorizations, and verifies state licensing information for physicians who read for contracted providers. Routine claim denials, EOB review, aging, payment posting, and collections remain with Billing. Management handles contract negotiations and final approvals. The position performs other related duties as assigned.

Requirements

High school diploma or GED, or six to eight years of related experience and/or training, or an equivalent combination of education and experience.
Experience with insurance payer enrollment for a healthcare organization, including Medicare, Medicaid, and commercial plans.
Knowledge of billing NPIs, taxonomy, payer participation, PECOS, and Medicaid enrollment portals.
Knowledge of Microsoft Word and Microsoft Excel.
Ability to read and interpret documents, write routine reports and correspondence, and speak effectively before groups of customers or employees.
Ability to perform basic arithmetic, calculate rates, ratios, and percentages, and interpret bar graphs.
Ability to solve practical problems, handle concrete variables where standardization is limited, and interpret written, oral, diagrammatic, or scheduled instructions.
Strong organization, follow-up, problem-solving, and communication skills.
Oral and written communication, diplomacy, customer relations and service, negotiation, organization, planning, professionalism, time management, budgeting, attention to detail, learning, decision-making, flexibility, leadership, and prioritization skills.
Ability to interpret and use ICD-10 codes.
Ability to meet the stated physical demands, including frequent sitting, hand use, reaching, and talking or hearing; occasional standing, walking, stooping, kneeling, crouching, or crawling; and occasional lifting or moving of up to ten pounds. Reasonable accommodation may be made for individuals with disabilities.

Nice To Haves

Experience with EDI, ERA, EFT, and payer portals.
Multi-state enrollment or mobile imaging experience.

Responsibilities

Handle enrollment and renewals with Medicare, Medicaid, commercial insurance plans, Medicare Advantage, and Medicaid managed care plans.
Confirm QMI’s participating plans, pending applications, and coverage effective dates; check payer records for the correct QMI business name and tax ID.
Complete credentialing forms for individual carriers, contact new insurance networks, follow up on participation, and communicate credentialing and participation information to QMI employees.
Set up and track electronic claim, remittance, and payment enrollments (EDI, ERA, and EFT); coordinate with Billing and clearinghouse support to confirm payer IDs, connections, and approvals, and notify Billing when connections are ready.
Manage or coordinate administrator access to insurance portals, including Availity, Optum, and state Medicaid systems; follow up on applications, enrollment errors, and out-of-network issues; manage approved staff access and help resolve login or permission issues.
Maintain current records of portals, administrators, users, and support contacts; maintain a payer tracker with plans, states, QMI entity/NPI, enrollment status, effective dates, and next steps; organize enrollment records; and report pending applications, renewals, and unresolved problems to management.
Liaise between facilities and radiology companies for credentialing purposes.
Research Billing issues caused by enrollment, network status, incorrect payer records, or electronic enrollment setup; work with payers to resolve problems and tell Billing whether affected claims can be resubmitted.
Maintain payer enrollment and provider-relations contacts; follow up on contracting and participation requests; determine payer requirements for QMI as a mobile imaging supplier. Management handles negotiations and final approvals.
Track Medicare and Medicaid revalidations, payer renewals, and other organizational enrollment deadlines; coordinate site surveys and paperwork with management; maintain organizational licenses or certifications needed for payer enrollment.
Assist Intake and Billing with insurance verification issues related to payer enrollment, participation status, and coverage discrepancies as needed.
Obtain and follow up on prior authorizations for diagnostic imaging services; verify payer-specific authorization requirements and submit clinical documentation; track pending authorizations, approvals, denials, and expiration dates.
Update each account verified to indicate verification is complete, and communicate authorization status and outstanding requirements to Intake and Billing.
Verify state-specific modality licensing for physicians who read for contracted providers; work with Intake to maintain current reading-doctor information and provide it in a format that supports Intake workflow.
Perform other related duties as assigned.