Provider Enrollment Specialist
Provider Enrollment Specialist
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Job Description
The Provider Enrollment Specialist administers the physician enrollment application process for payor enrollment. The Provider Enrollment Specialist is responsible for timely completion of government managed care and commercial payor enrollment applications via paper or online records and reporting demographic or other provider changes.
The Provider Enrollment Specialist will be responsible for the accuracy and integrity of the database system and related applications. Working under the supervision of the Credentialing and Contracting Manager they must be able to handle multiple simultaneous tasks effectively and efficiently and are expected to demonstrate ENCORE in all communications.
Essential Duties and Responsibilities
Reduce onboarding time for new providers by 5 annually
Maintain files no dropped recredentialing
Lead coordinate and perform the review and analysis of practitioner applications and accompanying documents ensuring applicant eligibility
Conduct thorough review research and primary source verification for licensing board certifications proof of professional liability insurance and/or other sources as required based on NCQA standards health plan requirements and company credentialing policies
Update and maintain all external credentialing systems including CAQH PECOS Availity and other required payer platforms
Complete enrollment with all clients contracted payers including Medicare Medicaid and other government and managed care plans for new client providers groups and/or locations
Ensure initial credentialing and recredentialing applications are completed and sent within defined departmental standards.
Ensure Medicare Medicaid and other payer revalidations/recredentialing applications are completed timely without lapse in enrollment.
Provide consistent and timely followup on all assigned outstanding items.
Respond to inquiries from internal and external customers on daytoday credentialing and privileging issues as they arise
Enter update and maintain all internal credentialing databases; prepare and provide information to internal and external customers as appropriate.
Process provider demographic changes ensuring appropriate documentation has been submitted with the changes update credentialing databases and notify health plans of changes.
Monitor initial reappointment and expirable process for all RBSE clients RBSE licensed staff and RBSE partners and delegated providers ensuring compliance with regulatory bodies (Joint Commission CMS federal and state) as well as Bylaws Rules and Regulations policies and procedures and delegated contracts
Complete thorough review of all client contracts and contract amendments ensuring that client rates are unaffected and provide the best possible reimbursement and procedures for the client.
Interact not only with payers but also with clients providers vendors RCM team and other business partners in a professional and positive manner.
Familiarity with RBS Revenue Cycle Structure Clients and Physicians
Reviews processes and provides suggestions for process improvements and efficiencies.
Other Expectations/Skills
A collaborative approach to assisting clients and staff.
Selfmotivated with the ability to problem solve.
Reliable and extremely trustworthy.
Program planning and implementation skills.
Database management.
Ability to maintain confidential and meticulous records.
Excellent verbal and written communication skills.
Proficient in Microsoft Office Suite or related software.
Exceptional organizational skills and attention to detail.
Superior analytical and technical skills.
Excellent keyboarding and administrative skills.
Other duties include followup on open applications with providers or payors.
ENCORE Values
Encourage others success
New ideas; anticipate problems
Contribute to teams efficiency by participating in staff meetings and contributing new thoughts and ideas for process improvements. Identify issues that require additional investigation and evaluation validate discrepancies and ensure appropriate followup.
Create financial value for our clients
- Maintain uptodate Credentialing Payer Grids for each Client showing all contracted payers providers and effective dates. The Gold Standard is to achieve aging goals in the same month 4 out of 6 rolling months.
- No missed or expired Medicare/Medicaid Revalidations for the calendar year.
- No items aging over 180 days
- Aging goal for Open Items over 90 days is below 20 of total open items
- Aging goal for Open Items over 120 days is less than 10 of total open items.
- Obtain 90 approval rating from client satisfaction surveys obtained.
Ownership towards a solution
Identify issues that fall through the cracks either here or on the client side before they create problems; use critical thinking skills to provide remedial solutions and develop preventive methods going forward. Ensure provider credentialing procedures are followed and timelines are met to prevent loss of revenue.
Reach Life Balance
Embody a positive approach
Actively engage in departmental client and other internal team meetings with a positive and upbeat attitude. Communication with clients and other RBS divisions should be positive and show an I can approach
College degree or equivalent experience.
3 years of experience performing credentialing and provider enrollment services typically gained in a hospital or physicians office preferred
Computerized practice management/credentialing systems and software preferred
CPCS (Certified Provider Credentialing Specialist) from NAMSS (National Association Medical Staff Services). Expected to have or obtain within one year of hire date.
Physical Demands and Work Environment: The physical demands described here are representative of those an employee encounters while performing the essential functions of this job. Reasonable accommodation may be made to enable individuals with disabilities to perform the functions.
Ability to lift/carry up to 25 pounds.
Ability to sit/stand for long periods of time.
Good manual dexterity with the ability to perform repetitive hand/wrist motions.
Requires mastery of complex language comprehension reasoning and analytical skills typically found in mid to highlevel work.
Typical office environment
Moderate noise levels
Disclaimer: This job description in no way states or implies that these are the only duties to be performed by the employee(s) of this position. Employees will be required to follow any other jobrelated instructions and to perform any other jobrelated duties requested by any person authorized to give instructions or assignments. All duties and responsibilities are essential functions and requirements and are subject to possible modification to reasonably accommodate individuals with disabilities.
The company is an equal opportunity employer drugfree workplace and complies with ADA regulations as applicable.
Required Experience:
Unclear Seniority
Employment Type
Full Time
