Payor Audit & Enrollment Specialist

Overview

The Specialist Payor Audit & Provider Enrollment serves as the organizations subject-matter expert for payor audit
response delegated credentialing oversight and provider enrollment data integrity. This role manages payor-initiated audits
from intake through resolution determining response strategy and authoring formal responses on behalf of the organization;
leads delegated credentialing audits and maintains continuous audit readiness against payor and accreditation standards;
and governs provider enrollment and billing data within DentalXchange and connected systems. Working under general
direction the Specialist interprets payor contracts delegation agreements and regulatory requirements exercises
independent judgment in assessing and escalating compliance and revenue risk and develops the policies controls and
reporting that govern these functions. The position advises Credentialing Compliance and Revenue Cycle leadership
partners across practice operations and billing and provides technical guidance and mentorship to credentialing and
enrollment staff.

Responsibilities

Payor Audit Strategy Response & Risk Mitigation
Serve as the organizations subject-matter expert and point of contact for payor-initiated audits arising from patient
complaints billing concerns quality-of-care allegations and grievances coordinating with the Credentialing
Manager who retains overall accountability for audit representation.
Independently evaluate each audit request to determine scope exposure and response strategy; design and
administer the centralized audit intake risk-tiering and tracking framework.
Analyze practice billing and clinical records to construct the factual record supporting each response then author
and submit formal written responses to payors exercising judgment on positioning disclosure and remediation
commitments and engaging Legal Clinical or Compliance partners where warranted.
Negotiate response timelines and extension requests with payor audit and network management contacts and
escalate matters of material risk network sanctions termination exposure repeat findings or systemic patterns
with a recommended course of action to the Credentialing Manager Compliance and operations leadership.
Analyze audit outcomes root causes and turnaround performance; translate findings into recommendations for
provider education workflow redesign and policy change.
Delegated Credentialing Oversight & Audit Readiness
Own the organizations delegated credentialing audit program interpreting each delegation agreement and
translating payor-specific obligations into internal standards controls and monitoring routines.
Lead the technical execution of pre-delegation and periodic delegated audits serving as the lead technical
representative to health plan delegation oversight teams in coordination with the Credentialing Manager.
Conduct internal file audits and mock audits against NCQA/URAC-aligned and payor-specific standards
determining where remediation is required and draft or update credentialing policies procedures and committee
documentation to maintain continuous audit readiness.
Draft and recommend corrective action plans in response to audit findings defining root cause remediation
approach ownership and completion criteria for Credentialing Manager review and approval; drive approved plans
to closure and validate sustained correction while advising Credentialing and Compliance leadership on delegation
risk and evolving accreditation or payor standards.
Provider Enrollment & Clearinghouse Data Governance (DentalXchange)

Serve as system subject-matter expert and data owner for provider enrollment information within DentalXchange
establishing the data standards validation rules and audit controls that govern it.
Define and maintain the end-to-end enrollment workflow connecting credentialing contracting and clearinghouse
activation including service-level expectations and hand-off criteria across departments.
Design and perform recurring data integrity reviews reconciling demographic NPI tax ID and enrollment data
against source credentialing records and diagnose complex enrollment rejections payor edits and connectivity
failures distinguishing isolated errors from systemic defects.
Serve as the designated system owner for the DentalXchange platform relationship managing support escalations
and configuration coordination (contracting and SLA management remain with the Credentialing Manager) and
establish controls ensuring provider status changes terminations location/name changes re-credentialing are
reflected accurately and timely across all connected systems.
Billing Data Integrity & Revenue Protection
Define the record-keeping standards and reconciliation cadence required to support clean claims submission and
continuous audit readiness across all practice locations.
Reconcile payor enrollment and effective-date records against credentialing and contracting status identifying gaps
that create denial or take-back exposure before claims are submitted.
Analyze denial and rejection trends attributable to enrollment or credentialing defects; quantify financial impact and
recommend corrective process or system changes maintaining the documentation architecture (fee schedules
enrollment confirmations EDI/ERA records) supporting billing-related audit responses.
Partner with Billing and Revenue Cycle leadership to prioritize remediation for providers or locations at risk of billing
disruption and advise on go-live readiness for new providers and acquired practices.
Program Governance Reporting & Continuous Improvement
Build and maintain the reporting package for payor audit volume outcomes cycle time delegated audit results and
enrollment data quality; present findings and recommendations to the Credentialing Manager Compliance and
Revenue Cycle partners.
Recommend and maintain key performance and risk indicators for the payor audit and enrollment data program
monitor performance against them and propose thresholds and corrective action where results fall short.
Monitor regulatory accreditation and payor policy changes affecting payor audit delegated credentialing and
provider enrollment; assess operational impact and implement required process documentation or system
changes.
Develop training and reference materials for credentialing billing and practice operations teams and represent the
payor audit and enrollment data function on cross-functional projects involving payor onboarding practice
integration and system implementations.
Scope Autonomy & Decision Authority:
Operates with substantial independence under general direction; sets own priorities and work methods and is
evaluated on program outcomes rather than task completion exercising independent judgment on matters of
significance such as audit response strategy risk classification and remediation priority.
Recognized technical authority on payor audit delegated credentialing and provider enrollment data; develops and
recommends policy standards and process changes for Credentialing leadership approval and adoption across
Credentialing Billing and practice operations. Decisions directly affect network participation compliance exposure
and claim revenue across all supported practice locations.
No direct reports; provides technical leadership and work direction to less-experienced credentialing and enrollment
staff.
Work Environment:
This is a full-time remote position supporting a multi-site multi-state practice environment. Work is performed in a home
office setting with reliable high-speed internet and a private secure workspace appropriate for handling confidential provider
patient and contractual information. The role collaborates virtually with Credentialing Compliance Billing Revenue Cycle
and practice operations partners and communicates directly with payors delegation oversight teams and the clearinghouse
vendor. Standard business hours apply with occasional extended hours to meet payor-imposed audit deadlines or
delegated audit schedules. Limited travel may be required for department or organizational meetings.
Physical Demands

This is a sedentary role. The position requires prolonged periods of sitting at a desk and working on a computer extensive
use of a keyboard mouse and monitors and frequent communication by telephone video conference and email. Must be
able to read review and analyze detailed documentation and data with accuracy and occasionally lift or move office
equipment or files weighing up to 15 pounds. Reasonable accommodations may be made to enable individuals with
disabilities to perform the essential functions of this position.
Competencies:
Analytical & Risk Judgment Evaluates complex audit contractual and enrollment data to identify risk
determine root causes and decide on the appropriate course of action.
Written & Verbal Communication Authors clear persuasive formal correspondence and explains complex
compliance and enrollment matters to payors leadership and staff.
Technical & Systems Proficiency Applies deep working knowledge of DentalXchange dental billing CDT
coding and EDI/ERA processes to manage enrollment data with accuracy.
Process & Program Ownership Designs documents and continuously improves audit-readiness controls
policies and reporting from the ground up.
Influence & Mentorship Advises senior leaders and guides less-experienced credentialing and enrollment staff
without formal supervisory authority

Qualifications

High school diploma or equivalent required; bachelors degree in healthcare administration business or a related
field preferred.
Six or more years of progressively responsible experience in dental or medical credentialing payor enrollment or
healthcare revenue cycle including demonstrated ownership of a program process or system rather than task-level execution.
Direct hands-on experience leading or materially supporting payor audits and delegated credentialing audits
including corrective action planning and closure.
Demonstrated experience interpreting payor contracts delegation agreements and NCQA/URAC-aligned
credentialing standards and applying them to operational decisions.
Experience in a multi-site multi-state healthcare or DSO environment strongly preferred.
CPCS CPMSM or comparable credentialing/compliance certification preferred.

Required Experience:

IC