Payor Enrollment Specialist

Payor Enrollment Specialist

The Payor Enrollment Specialist is responsible for all aspects of enrollment, credentialing, and re-credentialing of billable providers with all health plans and affiliated locations. Working under general supervision, this role provides administrative support for the organization's practitioner network to provide the best and most accessible patient care. Additionally, the Payor Enrollment Specialist must track and organize various provider documentation and data in accordance with local and regional compliance.

Essential Job Function:

• Enrolls system-wide health physician and non-physician practitioners (CRNA, physician assistant, nurse practitioner, LCSW, etc.) in government (Medicare/Medicaid) and managed care plans.
• Maintains and updates the credentialing system with effective dates of participation, re-enrollment deadlines and requirements, provider numbers, and credentials to reflect the most accurate provider and location information.
• Maintains current knowledge of licensure and certification requirements in order to complete provider credentialing and re-credentialing applications.
• Helps review and interpret federal and state law that govern Medicare Accountable Care Organizations and/or Medicare Advantage plans to ensure regulatory requirements are adequately documented and tracked for compliance.
• Tracks and documents copies of all required credentialing documentation for all providers to ensure timely renewals.
• Tracks and maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers and ensures timely renewals.
• Maintains knowledge of current health plan and agency requirements for credentialing providers.
• Complies with Medicare and Medicaid provider enrollment guidelines.
• Ensures accurate entry of data into CMS database for all CMS providers and suppliers.
• Requires understanding of CMS processes and requirements for rendering providers and service locations.
• Research enrollment issues and effectively communicates the progress of approved provider enrollments.
• Conducts follow-ups on credentialing, re-credentialing, revalidation, re-verification requests and demographic updates as received.
• Identifies issues requiring additional investigation and evaluation.
• Validates discrepancies and ensures appropriate follow up.
• Promotes appropriate escalation of enrollment issues toward timely resolutions.
• Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day enrollment issues as they arise.
• Performs other duties as assigned.

Education:

• Required: High school diploma or equivalent.
• Preferred: Associate's Degree.

Experience:

• Required: 2 years' experience in administrative support functions in a physician practice. Proficient with Microsoft Excel. Preferred: 2 years working experience with insurance, managed care, or medical staff credentialing.

Licensure/Certification/Listing: