Insurance Credentialing Specialist

Summary: Manage QMI’s insurance enrollments across seven states. Make sure QMI is enrolled correctly with each payer, stays current with renewals, and has the electronic connections needed for claims and payments. Assists with verification and authorization of patient insurance on claims where discrepancies exist to ensure eligibility. ^

^Insurance eligibility assistance will follow stabilization of the credentialing process

Duties and Responsibilities include the following. Other duties may be assigned.

Insurance Enrollment and Participation

1. Handle enrollment and renewals with Medicare, Medicaid, commercial insurance plans, Medicare Advantage, and Medicaid managed care plans.
2. Confirm which plans QMI participates with, which applications are pending, and when coverage takes effect. *
3. Check that payers have the correct QMI business name, tax ID*.
4. Responsible to complete all credentialing forms based on individual carriers*
5. Responsible for contacting new insurance networks and continue to follow up regarding participation. *
6. Responsible for communicating credentialing and participation information to QMI employees.

EDI, ERA, EFT & Clearinghouse Setup 

1. Set up and track electronic claim, remittance, and payment enrollments (EDI, ERA, and EFT). *
2. Work with Billing and clearinghouse support to confirm payer IDs, connections, and enrollment approvals. * 
3. Keep Billing informed when a payer connection is ready to use.

Payer Portal Access

1. Manage or coordinate administrator access for insurance portals, including Availity, Optum, and state Medicaid systems. follow up with payers on applications, enrollment errors, and out-of-network issues. * 
2. Add or remove approved staff access and help resolve login or permission issues.

Tracking and Follow-Up

1. Keep an up-to-date list of portals, administrators, users, and support contacts.
2. Keep one clear tracker showing each payer, plan, state, QMI entity/NPI, enrollment status, effective date, and next step. 
3. Save applications, approvals, payer emails, contracts, and other enrollment records where management can find them. 
4. Report pending applications, upcoming renewals, and unresolved problems to management.
5. Works as a liaison between facilities and radiology companies for credentialing purposes*

Enrollment Problems and Billing Support

1. Research problems Billing identifies that are caused by enrollment, network status, incorrect payer records, or electronic enrollment setup. 
2. Work with the payer to correct the problem and tell Billing when the issue is resolved and whether affected claims can be resubmitted. * 
3. Routine claim denials, EOB review, aging, payment posting, and collections remain with Billing. 

Payer Contacts and Contracts

1. Maintain contacts with payer enrollment and provider relations departments. * 

2. Follow up on contracting and participation requests. Management handles contract negotiations and final approvals.

3. Find out what each payer requires for QMI as a mobile imaging supplier. 

Renewals and Site Surveys

1. Track Medicare and Medicaid revalidations, payer renewals, and other organizational enrollment deadlines. * 

2. Coordinate site surveys and related paperwork with management. 

3. Maintain organizational licenses or certifications needed for payer enrollment.  

Insurance Verification/Authorization Support

1. Assists Intake and Billing with insurance verification issues related to payer enrollment, participation status, and coverage discrepancies as needed. *

2. Obtain and follow up on prior authorizations for diagnostic imaging services.

3. Verify payer-specific authorization requirements and submit necessary clinical documentation.

4. Track pending authorizations, approvals, denials, and expiration dates.

5. Responsible for updating each account verified to indicate that verification has been complete. Communicate authorization status and outstanding requirements to Intake and Billing.

Reading Doctors Verification

1. Verify licensing of modality by state for Physicians who read for contracted providers.

2. Work with intake to ensure they consistently have the most up to date reading doctor information.

3 Ensure the information is provided in a format that allows the information to be used in the most efficient manner for intake workflow.

4. Performs other related duties as assigned.

Qualifications:

To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or ability required. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

Language Ability:

Ability to read and interpret documents such as safety rules, operating and maintenance instructions, and procedure manuals. Ability to write routine reports and correspondence. Ability to speak effectively before groups of customers or employees of organization.

Math Ability:

Ability to add, subtract, multiply, and divide in all units of measure, using whole numbers, common fractions, and decimals. Ability to compute rate, ratio, and percent and to draw and interpret bar graphs.

Reasoning Ability:

Ability to solve practical problems and deal with a variety of concrete variables in situations where only limited standardization exists. Ability to interpret a variety of instructions furnished in written, oral, diagram, or schedule form.

Computer Skills:

To perform this job successfully, an individual should have knowledge of Microsoft Word and Microsoft Excel.

Education/Experience:

High school diploma or general education degree (GED); or six to eight years related experience and/or training; or equivalent combination of education and experience.in the following areas:

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. 
• Experience with EDI, ERA, EFT, and payer portals preferred. 
• Strong organization, follow-up, problem-solving, and communication skills. 
• Multi-state enrollment or mobile imaging experience is a plus. 

Knowledge, Skills, and Other Abilities:

 Oral communication skills

Written communication skills

Diplomacy

Customer relations

Customer service

Negotiations

Organization

Planning

Professionalism

Time management

Budgeting

Attention to detail

Ability to learn quickly.

Decision-making skills

Problem-solving skills

Flexibility

Leadership skills

Ability to prioritize.

Ability to interpret and use ICD-10 codes.

 Physical Demands:

The physical demands described here are representative of those that must be met by an employee to successfully perform the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

While performing the duties of this job, the employee is frequently required to sit; use hands; reach with hands and arms and talk or hear. The employee is occasionally required to stand; walk and stoop, kneel, crouch or crawl. The employee must occasionally lift and/or move up to ten pounds. Specific vision abilities required by this job include close vision and ability to adjust focus. 

Work Environment:

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the essential functions.

The noise level in the work environment is usually moderate.