Provider Enrollment Specialist

PLEASE NOTE - This position may require temporarily relocation to other TONHC Facilities: Sells Hospital, Santa Rosa Health Center, San Simon Health Center, and San Xavier Health Center.

Position Summary

Ensures professional licensing, training, and certification practitioners are enrolled and credentialed with all active system-wide payers and assists with site credentialing. The incumbent resolves problems according to established provider enrollment practices, guidelines, and compliance rules and standards.

Scope of Work: This position is located within the Tohono O'odham Nation Health Care (TONHC), Revenue Enhancement Branch (REB) on the San Xavier Health Center compound. Works under the general supervision of the REB Director.

Essential Duties and Responsibilities: (Depending on the area of assignment, an incumbent may not be required to perform some of the duties listed below):

• Facilitate initial payer enrollment applications upon the hiring of practitioners are complete and submitted.
• Regularly follow up on submitted payer enrollment applications status.
• Manage the ongoing re-enrollment process with payers.
• Create and maintain a payer enrollment file for each practitioner. Practitioner information contained in this file is considered confidential and handled as such.
• Maintain Practitioner's CAQH profile by entering data, supporting documents, and re-attesting quarterly.
• Maintain knowledge of current eligibility requirements, forms, and documentation required by each payer to add and maintain TONHC practitioner participation with each payer.
• Establish and maintain an effective professional relationship with the credentialing and provider relations staff of each payer.
• Provide monthly, quarterly, and annual reports to payers upon request and according to delegated credentialing agreements.
• Assist with pre-delegation, and annual payer audits in accordance with delegated credentialing agreements.
• Respond promptly to request from payers and various TONHC departments to answer any payer credentialing-related questions and work to solve credentialing-related issues.
• Regularly communicate with appropriate administrative staff regarding practitioners' standing with payers.
• Maintain a close working relationship with the TONHC Billing staff to facilitate the rapid resolution of credentialing-related issues.
• Provide support as needed in all aspects of the enrollment process for TONHC.
• Appropriately assign all new clinic sites a site National Provider Identifier (NPI) number, Medicaid TPI number, and Medicare PTAN number following Federally Qualified Health Centers (FQHC) or Fee for Service (FFS) guidelines.
• Add new practice locations to existing Medicare Part B Groups and create new Medicare Part B Groups for newly established FFS clinic sites.
• Ensure that all contracted payers (Medicaid MCOs and commercial payers) credential new clinic sites as they are established.
• Complete Medicare and Medicaid revalidation applications promptly to ensure all certifications are kept active and in good standing with the Centers for Medicare & Medicaid Services (CMS).
• Maintain knowledge of all FQHC and FFS requirements for certifying with Medicare and Medicaid.
• Be able to determine and fail validations when the information found is not in compliance with payer protocols.
• Performs other job-related duties as assigned.
  
  

Knowledge, Skills, And Abilities

• Knowledge of the Tohono O'odham culture, customs, and traditions.
• Knowledge of applicable federal, state, tribal laws, regulations, and requirements.
• Knowledge of the healthcare industry as it pertains to the functions of the position;
• Knowledge of provider enrollment for Medicare and Medicaid.
• Knowledge of legal regulations and requirements on confidentiality, specifically to the Privacy Act of 1974 and Health Insurance Portability and Accountability Act of 1996 (HIPAA).
• Knowledge of computer word processing, database programs, and other computer software for outgoing correspondence and provider's credentials.
• Knowledge in data entry and maintaining provider's enrollment information.
• Knowledge of the application process in filling out required fields specifically for provider enrollment numbers.
• Knowledge of identifying providers listed as locum tenens, contract, and temporary providers, to the part-time and permanent provider.
• Knowledge of English grammar, punctuation, spelling, and usage.
• Knowledge of provider enrollment information (i.e., Medicare, Medicaid, Workers Compensation and Insurance providers, their established procedures, required forms, etc.) associated with these various health insurance programs.
• Skill in using computer software programs to include MS Office Suite (Word, Excel, and Outlook).
• Skill in operating various word-processing, spreadsheets, and database software programs.
• Skill in providing superior customer service to external and internal customers.
• Ability to communicate effectively to the providers about what specific information is needed, the reason for that particular information, and can be able to ascertain that is as accurate as possible.
• Ability to use tactfulness and to deal effectively with persons of diverse backgrounds.
• Ability to use good public relations and possess a cooperative and considerate attitude toward others.
• Ability to organize and plan work.
• Ability to accomplish the quality and quantity of work expected within set limits of cost and time.
• Ability to establish and maintain cooperative and effective working relationships with the general public and co-workers.
• Ability to communicate efficiently and effectively both verbally and in writing.
• Ability to learn and adapt to changes in computer software and technology.
• Ability to maintain privileged, confidential information.
• Ability to work independently and meet strict timelines.
• Ability to work extended hours and various work schedules.
• Ability to apply customer service skills, positively representing the Nation while working with the public.
• Ability to handle multiple tasks and meet deadlines.
• Ability to travel within the interior/exterior boundaries of the Tohono O'odham Nation.
  
  

Minimum Qualifications

• Associate's Degree in Business or Healthcare and three years of health plan enrollment, credentialing, coding, and billing of primary care physicians; or an equivalent combination of training, education, and work experience which demonstrates the ability to perform the duties of this position.
  
  

Licenses, Certifications, Special Requirements

• CAQH experience preferred.
• Compliance with TJC, NCQA, and URAC standards experience,
• Upon recommendation for hire, a criminal background and a National FBI fingerprint check are required to determine suitability for employment, including a 39-month driving record.
• May require possessing and maintaining a valid driver's license (no DUIs or major traffic citations within the last three years).
• If required, must meet the Tohono O'odham Nation tribal employer's insurance requirements to receive a driver's permit to operate program vehicles.
• Based on the department's needs, incumbents may be required to demonstrate fluency in both the Tohono O'odham language and English as a condition of employment.