Enrollment Specialist

Enrollment Specialist

The Enrollment Specialist is responsible for coordinating, monitoring, and maintaining provider enrollment activities with commercial health plans, government payers, and other applicable healthcare organizations. This role serves as a key resource for provider enrollment by tracking applications, conducting payer follow-up, resolving enrollment discrepancies, and ensuring provider information is accurately maintained across payer systems.

In addition, the Enrollment Specialist supports provider credentialing updates, demographic maintenance, roster management, and Health Information Credentialing Excellence (HICE) audits. The position works collaboratively with Credentialing, Contracting, Billing, Operations, and other internal stakeholders to support timely provider enrollment and ongoing payer participation.

Essential Duties and Responsibilities

Coordinate and monitor initial and ongoing provider enrollment applications with commercial health plans, Medicare, Medi-Cal, and other applicable payers.

Track enrollment applications from submission through completion and maintain accurate status documentation.

Conduct routine follow-up with health plans and payer representatives regarding pending applications, missing information, processing delays, and enrollment determinations.

Identify enrollment issues and discrepancies and collaborate with internal departments and payer representatives to resolve them.

Monitor requests for additional documentation and ensure required information is obtained and submitted in a timely manner.

Maintain comprehensive enrollment tracking systems, databases, spreadsheets, and payer records.

Escalate delayed, denied, or otherwise problematic enrollments to leadership as appropriate.

Assist with provider demographic and practice location updates across payer systems.

Support provider credentialing and recredentialing activities.

Maintain and update provider affiliations, specialties, addresses, tax identification information, NPI information, and other payer-required data.

Ensure accurate provider information is maintained within CAQH, PECOS, NPPES, payer portals, and other applicable systems.

Review provider information for accuracy and identify discrepancies between internal records and payer databases.

Assist with provider roster reconciliation and coordinate correction of identified discrepancies.

Support credentialing and enrollment-related projects as assigned.

Assist with HICE audits and other internal or external compliance reviews.

Gather, organize, validate, and maintain provider enrollment and credentialing documentation for audit requests.

Review provider files to identify missing, incomplete, or inconsistent information.

Track audit-related action items and support timely completion of documentation requests.

Maintain organized records to support audit readiness and regulatory compliance.

Escalate compliance concerns or documentation deficiencies to leadership as appropriate.

Maintain accurate, complete, and confidential provider enrollment records.

Ensure enrollment activities and payer communications are thoroughly documented.

Prepare and maintain enrollment reports and status updates.

Identify recurring payer issues, enrollment trends, and process improvement opportunities.

Adhere to organizational policies, payer requirements, and applicable regulatory and compliance standards.

Core Competencies

Maintains a high degree of accuracy when reviewing provider information, enrollment applications, payer requirements, and supporting documentation.

Effectively manages multiple providers, payers, deadlines, and competing priorities while maintaining accuracy and timeliness.

Consistently monitors outstanding items and follows through to resolution.

Communicates professionally and effectively with providers, health plans, internal departments, and external stakeholders.

Investigates enrollment discrepancies, identifies root causes, and implements appropriate solutions or escalation pathways.

Takes ownership of assigned responsibilities and maintains accurate documentation and tracking.

Protects confidential provider, patient, organizational, and business information.

Collaborates effectively with Credentialing, Contracting, Billing, Operations, and other cross-functional teams.

Minimum Qualifications

High school diploma or equivalent required.

Associate's degree or Bachelor's degree in Healthcare Administration, Business Administration, or a related field preferred.

Two (2) or more years of experience in provider enrollment, credentialing, healthcare administration, medical group operations, payer operations, or a related healthcare environment preferred.

Experience working with commercial and/or government health plans preferred.

Experience using payer portals and provider databases preferred.

Proficiency with Microsoft Office applications, including Excel, Word, and Outlook.

Preferred Knowledge and Experience

Provider enrollment and payer participation processes.

Commercial and government payer requirements.

CAQH, PECOS, NPPES, payer portals, and provider roster management.

Provider credentialing and recredentialing processes.

Healthcare compliance requirements and audit documentation practices.

HICE audit standards and processes.

Provider demographic, affiliation, TIN, and NPI maintenance.

Physical Requirements and Work Environment

This position is primarily performed in an office or remote administrative environment and requires prolonged periods of:

Computer use and data entry.

Telephone and virtual communication.

Reviewing and maintaining electronic documentation.

Sitting and working at a workstation.

The role may require occasional participation in meetings, trainings, and interactions with internal and external stakeholders.