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BASIC FUNCTION

The Provider Enrollment Specialist oversees the process of credentialing clinical staff joining HealthPoint, a Federally Qualified Health Center (FQHC), with all HealthPoint’s payors and ensuring their privileges are aligned with their qualifications. Clinical Staff includes licensed practitioners (for example, Physician, Dentist, Physician Assistant, Nurse Practitioner), other licensed or certified practitioners (for example, Registered Nurse, Licensed Practical Nurse, Registered Dietician, Certified Medical Assistant), and other clinical staff providing services on behalf of HealthPoint (for example, Medical Assistants or Community Health Workers that do not require licensure or certification).

PRIMARY RESPONSIBILITIES AND DUTIES

1. Coordinate with Payors
   1. Coordinate with the Credentialing & Privileging Coordinator to ensure all HealthPoint providers are credentialed and recredentialed appropriately.
   2. Responsible for completing, submitting, and processing of enrollment applications with Medicare, Medicaid, etc. for new providers.
   3. Communicate with insurance companies, Medicaid, Medicare, all other HealthPoint payors, including those within the Accountable Care Organizations (ACOs), to facilitate credentialing and re-credentialing of providers.
   4. Resolve any issues or discrepancies in enrollment applications with payors, ensuring that all requirements are met, and applications are approved without delay.
   5. Maintain regular communication with payor representatives to stay informed about changes in payor enrollment requirements and processes.
   6. Develop and maintain a comprehensive understanding of the payor enrollment requirements of each payor, including specific requirements of each payor.

1. Maintain Credentialing Database
   1. Update and manage payor database to ensure all provider information is accurate and up to date across all payor types, including ACOs, Medicare, Medicaid, and all commercial insurance.
   2. Ensure that all payor enrollment data is entered correctly and promptly, and that any changes or updates are reflected in the database.
   3. Generate reports from payor database(s) as needed for internal and external use, including specific reports for ACOs, Medicare, Medicaid, etc.
   4. Manage the credentialing and recredentialing process for all HealthPoint clinical staff joining HealthPoint, ensuring compliance with federal and state regulations.
   5. Coordinate with various departments to gather and verify necessary documents, including but not limited to licenses, certifications, education, training, and relevant work history.
   6. Conduct primary and secondary source verification of credentials to ensure accuracy and validity.
   7. Conduct regular reviews of the database to identify and correct any discrepancies or errors.
   8. Analyze data trends to identify opportunities for process improvement and performance enhancement.

1. Credentialing and Privileging Oversight
   1. Manage the credentialing and recredentialing process for all HealthPoint clinical staff joining HealthPoint, ensuring compliance with federal and state regulations.
   2. Coordinate with various departments to gather and verify necessary documents, including but not limited to licenses, certifications, education, training, and relevant work history.
   3. Conduct primary and secondary source verification of credentials to ensure accuracy and validity.

1. Policy Development and Implementation
   1. Provide input in developing and implementing credentialing policies and procedures in alignment with accreditations and regulatory requirements.
   2. Continuously review and update credentialing policies and procedures in conjunction with the Compliance Department to reflect changes in regulations and best practices.

1. Respond to Inquiries and Reports
   1. Address inquiries from providers, payors, and internal staff regarding enrollment status and requirements for ACOs, Medicare, Medicaid, and commercial insurance, etc. providing clear and accurate information.
   2. Provide timely and accurate responses to payor provider enrollment-related requests, ensuring that all inquiries are resolved promptly and to the satisfaction of the requester.
   3. Maintain open lines of communication with providers, payors, and internal staff to facilitate the resolution of any issues or concerns related to payor enrollment.
   4. Document all inquiries and responses to ensure a clear record of communication and to identify any recurring issues that may need to be addressed.

1. Ensure verification of HealthPoint’s clinical staff of the following, as applicable:
   1. Current licensure, registration, or certification from a primary source
   2. Education and training for initial credentialing using:
      1. Primary sources for Licensed Independent Practitioners (LIPs)
      2. Primary or other sources (as determined by HealthPoint) for other licensed or certified practitioners (OLCPs) and any other clinical staff;
   3. Completion of a query through the National Practitioner Data Bank (NPDB), an electronic information repository containing information on medical malpractice payments and certain adverse actions related to health care practitioners, entities, providers, and suppliers;
   4. Clinical staff members identity for initial credentialing using a government-issued picture identification;
   5. Drug Enforcement Administration (DEA) registration; and
   6. Current documentation of basic life support training.
   7. Ensures initial and recurring review, every two years, of all clinical staff.

1. Ensures the following for privileging clinical staff, as applicable:
   1. Verification of fitness for duty, immunization, and communicable diseases status;
   2. For initial privileging, verification of current clinical competencies via training, education, and as available, reference reviews;
   3. For renewal of privileges, verification of current clinical competence via peer review or other comparable methods (for example, supervisory performance reviews; and
   4. Maintain records of all clinical staff’s denial, modification, or removal of privileges based on assessments of clinical competence and/or fitness for duties
   5. Maintain updated credentialing and privileging files and databases, ensuring completeness and accuracy of information.

1. Collaboration and Communication
   1. Collaborate with internal stakeholders, including medical staff, human resources, compliance, and legal departments, to ensure alignment with compliance with the payor enrollment requirements.
   2. Serve as a liaison between providers and external agencies, such as insurance companies and government entities, regarding payor enrollment matters.
   3. Communicate payor enrollment decisions and updates to providers in a timely and professional manner.

1. Quality Assurance and Compliance
   1. Conduct regular audits on payor enrollment files and processes to ensure compliance with regulatory standards.
   2. Participate in internal and external audits related to payor enrollment as well as the credentialing and privileging coordinator.
   3. Identify and address areas for improvement in the provider payor enrollment processes to enhance efficiency and effectiveness.

1. Data Management and Reporting
   1. Generate reports and maintain accurate records related to provider credentialing and privileging activities.
   2. Analyze data trends to identify opportunities for process improvement and performance enhancement.

1. Training and Education
   1. Provide training and education to providers and staff on payor enrollment requirements, processes, and best practices.
   2. Offer guidance and support to provide throughout the payor enrollment process, addressing any questions or concerns.

1. Risk Management
   1. Identify and mitigate risk associated with payor enrollment processes to ensure patient safety and quality of care.
   2. Implement measures to address any potential legal or regulatory issues related to provider enrollment with payor(s).

1. Professional Development
   1. Stay abreast of changes in healthcare regulations, accreditation standards, and industry trends related to provider payor enrollment.
   2. Participate in professional development activities, such as conferences and workshops, to enhance knowledge and skills in provider payor enrollment practices.

Effectively carries out tasks and responsibilities beyond core job duties and primary role. The additional duties may vary from time to time and encompass a wide range of activities that contribute to the overall success of the organization (floating, schedule variations, assisting co-workers, patients, visitors, customers, leaders, and other stakeholders in support of the organization.)

GENERAL PROFESSIONAL DEVELOPMENT

1. Displays more advanced organizational skills, in order to organize projects or the work of others. (Level 3)
2. Devises effective solutions to situations encountered based on the general goals and objectives of the function. (Level 4-5)
3. Able to effectively communicate opinions drawn from conclusions using inference and logic. (Level 3)
4. Resolves conflicts that may arise because of disagreements between employees, between employees and customers/clients, or with the public, other legal entities or governmental authorities. (Level 3 & 4)

PROFESSIONAL/TECHNICAL KNOWLEDGE, SKILLS & ABILITIES

1. Possesses advanced work-related skills beyond completion of high school, including written and verbal communications skills, computational and computer skills, mathematical, technical or health care related knowledge frequently acquired through completion of a licensed skilled trade, para-profession or practical business knowledge.
2. Possesses knowledge and training in the field of credentialing and privileging coordination.
3. Possesses an understanding of the trade/profession at a level that allows the employee to select methods for others to use (from those already in existence in the profession). (Level 4)
4. Maintains current knowledge of standards of care and practices, typically acquired through continuing medical education.

LICENSES & CERTIFICATIONS

1. Education: High School Diploma or equivalent.
2. Knowledge of healthcare regulations such as HIPAA, Stark Law, and Anti-Kickback Statute.
3. Familiarity with accreditation standards, such as those with the Health Resource and Services Administration (HRSA).
4. Proficiency in using credentialing software and databases.
5. Driver’s License.
6. Preferred:
   1. Certified Provider Credentialing Specialist (CPCS) certification or Certified Professional in Medical Services Management (CPMSM) certification from the National Association Medical Staff Services (NAMSS).
   2. Experience in healthcare administration, credentialing, and privileging.
   3. Experience in credentialing f major payers such as Medicare, Medicaid, Tricare, BCBS, Aetna, Cigna, Humana and other commercial and managed plans.

TECHNICAL SKILLS

1. Creates highly complex documents in Microsoft Word, including linking multiple files and embedding objects linked to other documents.
2. Uses advanced functions of Microsoft Excel, such as to create and manage databases, including creating standardized reports, or link multiple worksheets and workbooks.
3. Develops sophisticated presentations in Microsoft PowerPoint, including the use of embedded objects, transitions, and other elements.
4. Demonstrates necessary proficiency with all electronic clinical systems, including EHR and scheduling systems, in use at the health center.

COMMUNICATIONS SKILLS