Provider Enrollment & Credentialing Specialist (2072)

Position Summary

Be the first point of contact to staff; resolve enrollment & credentialing issues by answering questions, making recommendations for resolution and escalation, checking enrollment status, verifying payer enrollment requirements and system implementation, appropriately follow-up on Provider Issue Forms; facilitates group and individual enrollment with commercial and government payers.

Responsibilities:

• Resolves issues and concerns by correctly answering questions from staff and providing appropriate follow-up on issues, escalating to Team Manager, when appropriate


• Provides the team with coaching, training, and auditing on assigned tasks. Partner with Team Manager to evaluate team’s performance to improve overall production and facilitate continuous improvement.


• Assists Team Manager in monitoring inventory and production and facilitates the escalation process as needed.


• Become proficient in discussions with payors to facilitate closure of any identified issues.


• Research and review individual Provider Issue Forms for appropriate follow-up and resolution.


• Maintain Matrices - payer enrollment, matrix, SOPs, new site sheets, email templates, welcome letters, etc.


• Create and distribute reports containing provider credentialing and enrollment data for various departments within the organization.


• Research new state enrollment requirements for group and individual provider enrollment.


• Assists Contract Implementation staff with accurately documenting enrollment and billing requirements for payer contracts.


• Maintain and complete new entries in Veritystream.


• Facilitate completion and submission of payer enrollment applications for government and commercial payers.


• Monitor application status process to identify emerging issues and communicate them to Team Manager.


• Monitor enrollment status for groups and individuals.


• Monitor license and credential expiration dates and advise staff members of required “renew” by dates.


• Maintain accurate provider profiles on CAQH, PECOS, NPPES, and CMS databases.


• Maintain individual provider files to include up to date information needed to complete the required governmental and commercial payer credentialing applications.


• Apply for and renew annually all provider licenses; Professional, DEA, Controlled Substance


• Complete revalidation requests issued by government payers.


• Credential new providers and re-credential current providers with hospitals at which they hold staff privileges.


• Work closely with the Director of Revenue Cycle and billing staff to identify and resolve any denials or authorization issues related to enrollment & credentialing.


• Performs and assists with other department duties as required.

Knowledge, Skills and Abilities Required:

• Meticulous follow-through of delegated tasks, including follow-up with staff to ensure completion, quality, and meeting deadlines.


• Ability to exhibit leadership by demonstrating commitment to team development, adapting to change in a positive manner, and supporting alignment with organizational goals including continuous improvement efforts.


• Ability to pay close attention to detail and produce extremely accurate work.


• Strong analytical and problem-solving skills.


• Ability to organize and prioritize job tasks and requirements.


• Excellent organizational skills with the ability to prioritize assigned duties in an efficient amount of time.


• Ability to effectively perform in a multi-task work environment.


• Strong communication and interpersonal skills.


• Ability to effectively use oral and written communication skills with clinicians, external agencies and management in a courteous and professional manner.


• Must have knowledge of correct English, proper grammar and spelling.


• Knowledge and skills in using personal computers (Windows) with a strong emphasis on Microsoft Office Programs- Outlook, Word, Excel and Adobe Acrobat

Education & Experience:

• High school diploma or equivalent


• Two (2) years office experience or college course work preferred.


• Knowledge of health plan billing and enrollment preferred.


• PECOS and CAQH experience preferred.


• Veritystream experience a plus.