Provider Enrollment Specialist

Provider Enrollment Specialist

Provider Enrollment Specialist is to perform enrollment, reassignment and re-enrollment related functions for providers with commercial insurance carriers and government payers, as needed. This position serves as a resource and liaison to implement and resolve issues related to enrollment for reimbursement. This position will work directly with credential teams and payers as well as our employed physicians and advanced practice clinicians to ensure all applications are completed within specified time periods. Maintains working knowledge of CAQH, PECOS, SC DHHS, NC Tracks and NPPES and any other payer enrollment portal.

Minimum Requirements

Education

• High School Diploma or its equivalent

Experience

• Two years of applicable experience or three years in working in managed care, credentialing or revenue cycle
• Proficient with payer portals, and Microsoft Office Suite

License/Registration/Certifications

• N/A

Preferred Requirements

Preferred Education

• Associate degree

Preferred Experience

• Five years of applicable experience
• Proficient with credentialing software, payer portals, and Microsoft Office Suite.

Preferred License/Registration/Certifications

• Certified Provider Enrollment Specialist (CPES) or Certified Provider Credentialing Specialist (CPCS)

Core Job Responsibilities

• Obtains, verifies, and analyzes all required information pertinent to payer enrollment
• Organize the payer enrollment process to meet the required timelines
• Interfaces with health plan contacts to understand and support the credentialing application and completion process
• Prepare, submit and track payer enrollment applications, reassignment, reenrollment and demographic updates to payers
• Performs ongoing follow-up with payers to ensure completeness of payer applications
• Perform tracking and follow-up to ensure provider numbers are established and linked to the appropriate group entity in a timely manner
• Ensure ongoing data entry accuracy and completeness of providers in the enrollment system
• Working knowledge of CAQH, PECOS, SC DHHS, NC Tracks and NPPES to ensure taxonomy codes are appropriate per specialty of practice and billing requirements.
• Submits Annual Disclosures of Ownership (ADOs) and re-validations to Medicare & Medicaid on all providers and practices as assigned
• Participates with the team to implement and adhere to policies, procedures, and systems to ensure timely data entry in credentialing platform
• Maintain accurate provider records in the credentialing platform to serve as the single source of truth, ensuring data integrity, regulatory compliance, and timely claims processing
• Maintain enrollment information within the credentialing database and pull reports for hospital administration, marketing, professional billing staff, and clinic directors/managers, as needed
• Ensures adherence to objectives, operating policies and procedures, and strategic action plans for achieving goals
• Collaborate with supervisor to create new processes and procedures needed to improve overall processes
• Collaborate with the credentialing team to gather necessary provider documentation for enrollment
• Communicate clearly with stakeholders regarding application status, required next steps, and potential impacts on claims processing
• Identifies and reviews red flags with managers and directors
• Responsible for learning the aspects of compliance by completing all mandatory compliance training
• Ability to comply with standards of operations
• Ability to adhere to the commitment values, of teamwork, communication, empowerment, quality of data integrity
• Other duties as assigned