Provider Enrollment Specialist

Job Description

Job Description

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 on-line 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 re-credentialing 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 follow-up on all assigned outstanding items.
• Respond to inquiries from internal and external customers on day-to-day 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

ENCORE Values

Encourage others’ success

New ideas; anticipate problems

Contribute to team’s 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 follow-up.

Create financial value for our clients

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

Requirements :

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.

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 job-related instructions and to perform any other job-related 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, drug-free workplace, and complies with ADA regulations as applicable.