Provider Enrollment Specialist

Position Title:
Provider Enrollment Specialist

Department:
Medical Staff/Credentialing

Job Description:

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Remote Eligibility: Candidates must reside and work full-time in AR, KS, MO, OK, or TX before their first day of employment.

General Description:

Under minimal supervision, the Provider Enrollment Specialist II performs comprehensive enrollment functions while demonstrating a deep understanding of organizational practice locations and associated group contracts. In addition to executing the end-to-end enrollment lifecycle for federal and managed care plans, this role proactively manages complex clinic data and directly communicates with health plan oversight representatives regarding NCQA implementation. The Specialist II serves as a senior-level technical resource, creating complex ad-hoc rosters and ensuring that all practice-specific data, including clinic NPIs and group contract numbers, is accurate and current within the organization's billing infrastructure.

Essential Responsibilities:

Responsibilities listed in this section are core to the position. Inability to perform these responsibilities, with or without an accommodation, may result in disqualification from the position.

• Execute all core duties of the enrollment lifecycle, including contract initiation, reassignment of benefits, and the maintenance of billing privileges.
• Manage updated group practice location information in the enrollment database, including clinic hours, clinic NPIs, group contract numbers, and contact information.
• Lead participation in delegation oversight reviews, serving as a technical resource for health plan reviewers and demonstrating compliance with standards.
• Create complex ad-hoc reports and rosters within the enrollment software to meet diverse health plan data requests and delegation reporting requirements.
• Communicate directly with health plan and delegation oversight representatives regarding NCQA standards and the organizational implementation of those standards.
• Utilize government and state-specific healthcare enrollment portals to maintain master provider records and complex billing eligibility.
• Direct ongoing communication with the Revenue Cycle department to resolve persistent enrollment roadblocks and ensure reimbursement accuracy.
• Coordinate the maintenance of National Provider Identifiers (NPI) within national registries, ensuring seamless integration with health system billing.
• Analyze practitioner sanctions or adverse disclosures to ensure they are communicated accurately and discreetly to health plans during the enrollment phase.
• Submit timely revalidations and contract renewals, proactively identifying potential gaps in state or federal contract eligibility.
• Optimize the use of enrollment software to track health plan effective dates and provide real-time updates to organizational stakeholders.
• Resolve complex claim holds and denials by investigating deep-rooted credentialing or enrollment discrepancies that affect the revenue cycle.

General Responsibilities:

• Performs other duties as assigned.

Minimum Qualifications:

Education: High School diploma or G.E.D. required.

Experience: At least 3 years of experience in provider enrollment, health plan administration, or medical staff services required.

License(s)/Certification(s)/Registration(s) Required: Certified Provider Enrollment Specialist (CPES) or Certified Provider Credentialing Specialist (CPCS) by the National Association Medical Staff Services (NAMSS) required, or obtained within 12 months of hire.

Knowledge, Skills and Abilities:

• Advanced knowledge of NCQA accreditation standards and the regulatory environment governing provider enrollment and delegation.
• Enhanced communication skills with the ability to navigate discussions with health plan auditors and executive leadership.
• Mastery of healthcare-specific database functionality, specifically in the creation of complex rosters and custom data extracts.
• Advanced understanding of government enrollment portals and national provider registries.
• Proven ability to manage complex group practice data across multiple locations and Tax IDs.
• Ability to identify process bottlenecks and implement collaborative solutions to improve enrollment turnaround times.
• Skill in analyzing health plan contracts to determine specific enrollment requirements for a diverse provider population.

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OU Health is an equal opportunity employer. We offer a comprehensive benefits package, including PTO, 401(k), medical and dental plans, and many more. We know that a total benefits and compensation package, designed to meet your specific needs both inside and outside of the work environment, create peace of mind for you and your family.