Provider Enrollment Specialist II

POSITION DESCRIPTION:

The Provider Enrollment Specialist II is responsible for all aspects of the credentialing, re-credentialing process for all providers.  Responsible for ensuring providers are credentialed, appointed and privileged with health plans and hospitals.  Maintains up to date data for each provider in credentialing databases and online systems; ensures timely renewal of license and certifications.  Understands the insurance plan requirements for credentialing all types of providers.

ESSENTIAL JOB FUNCTIONS:

1. Compiles and maintains current and accurate data for all providers.
2. Maintains copies of current state license, DEA certificates, board certifications and any other required credentialing documents for all providers.
3. Maintains knowledge of current health plan and hospital requirements for credentialing providers.
4. Sets up and maintains provider information in online credentialing databases and systems.
5. Tracks licenses and certification expirations for all providers to ensure timely renewals.
6. Performs new facility credentialing processes with all new mergers.
7. Provides support to Central Billing Office regarding provider effective dates / provider numbers and keeps appropriate IHA personnel informed as to the status of credentialing of new providers.
8. Prepares, submits and follows up on credentialing and enrollment applications and ensures that supporting documentation is collected and provided to plans/hospitals as needed in a timely manner.
9. Establishes and maintains provider files to include necessary documentation and understands the plan requirements for credentialing a provider with all of insurance carriers we currently participate with for all types of providers.
10. Follows up on the status of applications and provider licenses and facilitates the renewal process; tracks the progress on all pending applications and works to resolve issues as they arise.
11. Maintains and updates provider online database, tracks licensure expirations and ensures that updated licensures are received.
12. Assists with maintenance of Insurance Participation list by keeping provider numbers current, updating insurance information.
13. Ensures signed applications are received from providers as well as they are being sent to the plans and is aware of carrier timelines/committee approval schedules. Performs CAQH updates and maintenance.
14. Coordinates the National Provider Identifier application for all new hire providers /offices and updates existing physicians’ information.
15. Sends Practice Managers a credentialing status spreadsheet before a new provider starts, updating on a weekly basis.
16. Brings areas of concern and recommendations to Provider Relations Manager. 
17. Maintains familiarity with CBO policies and procedures.
18. Supports special project work, as needed.
19. Assumes additional duties, as required.

ORGANIZATIONAL EXPECTATIONS:

1. Creates a positive, professional, service-oriented work environment by supporting the mission and values of both IHA and Trinity Health.
2. Must be able to work effectively as a member of the Provider Relations team.
3. Assumes responsibility for performance of job duties in the safest possible manner, to assure personal safety and that of coworkers, and to report all preventable hazards and unsafe practices immediately to management.
4. Successfully completes IHA’s “Our Experience” training and adheres to IHA’s standard of promptly providing a high level of service and respect to internal or external customers.
5. Maintains knowledge of and complies with IHA standards, policies and procedures.
6. Maintains general knowledge of IHA office services and in the use of all relevant office equipment, computer and manual systems.
7. Maintains strict confidentiality in compliance with IHA and HIPAA guidelines.
8. Serves as a role model by demonstrating exceptional ability and willingness to take on new and additional responsibilities.  Embraces new ideas and respect cultural differences.
9. Uses resources efficiently.
10. Responsible for ongoing professional development – maintains appropriate licensure/certification and continuing education credentials, participates in available learning opportunities.

MEASURED BY:

Performance that meets or exceeds IHA CARES Values expectation as outlined in IHA Performance Review document, relative to position.

ESSENTIAL QUALIFICATIONS:

EDUCATION:  Associate’s degree. Candidates with comparable combination of education and related experience may be considered.

CREDENTIALS/LICENSURE: N/A

MINIMUM EXPERIENCE:  1-3 years’ previous credentialing/enrollment or provider relations experience, or Bachelor’s degree in related area.

POSITION REQUIREMENTS (ABILITIES & SKILLS):

1. Substantial knowledge of provider credentialing.
2. High level of skills in operating a standard desktop and Windows-based computer system including, but not limited to, Microsoft Word, Excel, PowerPoint, Outlook, database applications, presentation software, Intranet and computer navigation.
3. Excellent communication skills in both written and verbal forms, including proper phone etiquette.  Ability to speak before groups of people, either in-person or virtually.
4. Excellent interpersonal and networking skills, especially with physicians, medical staff leadership and administrative leadership.
5. Ability to work collaboratively in a team-oriented environment; displays courteous, professional and friendly demeanor.
6. Ability to work effectively with various levels of organizational members and diverse populations.
7. Ability to cross-train in other areas of the department in order to achieve smooth flow of all operations.
8. Excellent organizational, analytical, time management and attention-to-detail skills for the execution of multiple assignments. Ability to work independently with minimal supervision, plan, organize, prioritize assignments and responsibilities and time constraints in a fast-paced environment and adapt to them as they change frequently; work concurrently on a variety of tasks/projects in an environment that may be stressful with individuals having diverse personalities and work styles.
9. Ability to exercise sound judgment and problem-solving skills.
10. Ability to maintain any organizational information in a confidential manner.
11. Ability to work overtime, as scheduled.