Specialist-Payer Enrollment

Job Summary:

With direct impact on reimbursement timelines patient satisfaction and regulatory compliance the Payer Enrollment Specialist plays a foundational role in healthcare administration. By ensuring timely and accurate enrollment of healthcare providers with commercial and government payers this position directly contributes to the financial health of the organization and uninterrupted access to care for patients. Effective payer enrollment minimizes delays in reimbursement supports provider scheduling and ensures compliance with payer-specific and regulatory requirements. The specialist serves as a liaison between providers internal departments and payers to streamline application processing manage revalidations and resolve enrollment-related issues. Attention to detail understanding of credentialing standards and proactive communication are essential for success in this role.

Job Responsibilities:

• Verify all required documentation for provider enrollment with insurance payers (e.g. applications licenses certifications).
• Submit enrollment applications and documentation required for both new providers as well as location adds or practice changes
• Maintain and update records of provider enrollment status ensuring that all information is accurate and up-to-date.
• Complete timely revalidation through payer portals recredentialing applications or profiles such as CAQH to ensure that providers maintain enrollment with commercial and governmental payers.
• Follow up with payers to ensure timely and accurate processing of provider enrollments within payer-specific turnaround time metrics communicating directly with payer representatives to resolve enrollment issues or discrepancies and escalating trends or new payer requirements to leadership
• Monitor payer enrollment timelines and ensure that all required steps are completed in a timely manner to avoid delays in provider participation.
• Address provider inquiries regarding enrollment status billing issues or payer-specific requirements.
• Coordinate with other internal departments (e.g. credentialing billing) to ensure that enrollment information is aligned across systems.
• Research and maintain current knowledge of payer-specific enrollment requirements and changes ensuring that provider data is compliant with payer guidelines.
• Support the creation and maintenance of documentation for payer enrollment processes and procedures.
• Monitor and Resolve Enrollment-Related Claim Denials: Investigate and resolve claim denials or rejections related to provider enrollment issues including missing or incorrect NPI TIN or payer ID information.
• Maintain Accurate Provider Data: Ensure provider information is accurately reflected in payer systems to prevent claim processing delays or denials.
• Follow Up with Payers: Communicate with insurance payers to verify provider enrollment status and resolve any issues affecting claims adjudication.

Experience

• 2 years focused payer enrollment experience

Education

• High School/GED
• Medical Billing or Credentialing/Payer Enrollment certificate from an accredited facility.