Credentialing & Compliance Specialist CrossRoads of Southern Nevada Las Vegas, NV Job Details Full-time $25.28 - $30.44 an hour 1 hour ago Benefits Health insurance Dental insurance 401(k) Paid time off Vision insurance 401(k) matching Life insurance Referral program Qualifications Microsoft Word Computer operation Teamwork Microsoft Excel Computer literacy Taxonomy Regulatory legal research Medicaid health insurance Attention to detail Medicaid regulations Medicaid Quality audits Time management Full Job Description The Credentialing & Compliance Specialist's key role is to support CrossRoads of Southern Nevada's Billing and Revenue Cycle operations by maintaining organizational and provider credentialing, payer enrollment, Medicaid compliance, billing compliance, and quality assurance. The Credentialing & Compliance Specialist will serve as a primary internal resource for Nevada Medicaid requirements, Medicaid provider types, payer credentialing requirements, billing regulations, and reimbursement guidelines. This position is expected to actively research and remain current on Nevada Medicaid Services Manuals, provider bulletins, billing guidance, regulatory changes, new provider types, covered services, and other payer requirements that may impact CRSN's operations or reimbursement. The Credentialing & Compliance Specialist will work closely with Billing, Revenue Cycle, Quality Assurance, Clinical, Programs, Medical, and Executive Leadership to help ensure CRSN remains appropriately credentialed, compliant, and positioned to capture allowable reimbursement opportunities.

Supervision Received and Exercised:

The Credentialing & Compliance Specialist will report directly to the Director of Revenue . This is a non-supervisory specialist position; however, the employee is expected to independently research credentialing, Medicaid, billing, payer, and compliance matters and provide findings and recommendations to the Director of Revenue.

Responsibilities:

The personnel in this role will directly report to the Director of Revenue and be willing to take on tasks of the following nature: Manage organizational, facility, and individual provider credentialing with Nevada Medicaid, Medicaid Managed Care Organizations (MCOs), and commercial insurance payers. Complete and maintain payer enrollment, credentialing, recredentialing, and revalidation applications. Maintain accurate provider and organizational NPI, taxonomy, TIN/EIN, W-9, licensing, accreditation, insurance, CAQH, and other credentialing information. Track credentialing applications from submission through approval and maintain accurate effective dates. Maintain and routinely reconcile payer provider rosters. Process provider additions, terminations, location changes, and demographic updates. Ensure applicable providers, facilities, and locations are appropriately credentialed and enrolled prior to billing. Routinely review Nevada Medicaid Services Manuals, provider bulletins, billing guidance, enrollment requirements, and regulatory updates. Research state and federal Medicaid regulations applicable to CRSN services. Maintain an in-depth understanding of Medicaid billing and reimbursement requirements. Monitor changes in covered services, provider qualifications, documentation requirements, billing rules, reimbursement methodologies, and service limitations. Research existing, new, and changing Nevada Medicaid provider types. Identify provider types and services for which CRSN may potentially qualify. Research requirements associated with new provider types, including licensing, staffing, certification, documentation, enrollment, and billing requirements. Research applicable CPT, HCPCS, revenue codes, modifiers, taxonomy, place-of-service requirements, and other billing requirements. Identify potential new Medicaid and payer reimbursement opportunities and present findings to the Director of Revenue. Research Medicaid and commercial payer billing requirements prior to implementation of new programs or services. Work with Billing/Revenue Cycle staff to research credentialing and enrollment-related claim denials. Assist in resolving payer issues involving provider enrollment, taxonomy, service location, credentialing, or payer configuration. Identify potential revenue loss associated with credentialing, enrollment, or payer compliance issues. Conduct routine quality assurance reviews of credentialing and enrollment records. Review payer rosters against active organizational providers. Monitor licenses, certifications, credentialing, recredentialing, and enrollment expiration dates. Assist with targeted billing compliance and documentation reviews. Identify trends in denials that may indicate credentialing, billing, documentation, or payer compliance concerns. Document quality assurance findings and recommend corrective actions. Track identified corrective actions through resolution. Assist with Medicaid, MCO, and commercial payer audits and requests for documentation. Maintain an organized credentialing and compliance tracking system. Provide regular credentialing, Medicaid, compliance, and quality assurance updates to the Director of Revenue. Communicate significant regulatory changes, compliance concerns, and potential revenue impacts to the Director of Revenue. Work collaboratively with other departments to help translate Medicaid and payer requirements into operational practices. Maintain confidentiality of provider, organizational, financial, and other protected information. Other duties assigned by the Director of Revenue or Executive Leadership.

Prerequisite Job Requirements:

Strong computer skills. Proficient in Microsoft Word and Excel. Strong written and verbal communication skills. Strong organizational and time-management skills. Exceptional attention to detail. Strong research and analytical skills. Ability to read, interpret, and summarize complex regulatory and payer guidance. Experience in healthcare credentialing, provider enrollment, medical billing, revenue cycle, compliance, or a related healthcare field. Knowledge of Medicaid and commercial insurance processes. Knowledge of NPI, taxonomy, CAQH, payer enrollment, and credentialing processes. Experience with Nevada Medicaid preferred. Experience in behavioral health and/or substance use treatment preferred. Knowledge of healthcare billing, coding, reimbursement, and quality assurance preferred. Ability to independently research regulatory questions and present findings in a clear and understandable manner. Ability to manage multiple applications, deadlines, renewals, and follow-up requirements simultaneously.

Results Expected:

Maintain accurate and current organizational and provider credentialing records. Maintain appropriate credentialing and enrollment with Medicaid, MCOs, and commercial insurance payers. Prevent avoidable credentialing or enrollment lapses caused by missed internal deadlines. Ensure credentialing applications are completed accurately and followed through to resolution. Maintain accurate and current payer provider rosters. Maintain an in-depth working knowledge of Nevada Medicaid requirements applicable to CRSN services. Routinely monitor Medicaid manuals, bulletins, billing guidance, and regulatory changes. Communicate significant Medicaid and payer changes to the Director of Revenue in a timely manner. Identify how regulatory changes may impact CRSN operations, billing, compliance, and reimbursement. Routinely research new Medicaid provider types and potential reimbursable services. Identify potential opportunities to expand CRSN's Medicaid participation when appropriate. Identify credentialing, enrollment, billing, and compliance concerns before they result in significant reimbursement problems whenever reasonably possible. Complete assigned quality assurance reviews and audits accurately and timely. Track identified compliance concerns and corrective actions through resolution. Assist in reducing credentialing and enrollment-related claim denials. Maintain organized documentation capable of supporting internal, payer, and regulatory audits. Demonstrate ownership and follow-through by researching identified problems, determining applicable requirements, and presenting recommended next steps rather than simply identifying the issue. Maintain effective communication and collaboration with the Director of Revenue, Billing, Quality Assurance, Programs, Clinical, Medical, and Executive Leadership. Protect the organization's ability to remain credentialed, compliant, bill accurately, receive appropriate reimbursement, and identify new Medicaid opportunities.

Pay:

$25.28 - $30.44 per hour Expected hours: 40.0 per week

Benefits:

401(k) 401(k) matching Dental insurance Health insurance Life insurance Paid time off Referral program Vision insurance

Work Location:

In person