Provider Enrollment Specialist

3 weeks ago

Wilmington, Delaware, United States Nemours Full time
Nemours is seeking a Provider Enrollment Specialist (hybrid) to join our Nemours Children's Health team in Delaware or Florida.

This position is responsible for administrative and technical duties that require accuracy and attention to detail in the enrollment and reenrollment of our organization and its healthcare providers with all out of state Medicaid plans that we are required to enroll to be reimbursed for services. This position engages with internal and external customers, including physicians and other healthcare providers, administrators, support staff and state representatives. This position requires excellent communication and organizational skills, the ability to prioritize tasks and projects and the capacity to know to act independently but also know when to ask for guidance. Additionally, this position is responsible for communicating provider participation information to stated internal and external customers through established processes to allow for appropriate patient scheduling and reimbursement for services rendered.

Accurately completes the enrollment/reenrollment processes and manage expirables ensuring the timely and accurate enrollment of providers as outlined by each out of state Medicaid plan for all appropriate healthcare providers as identified through our department policies and our single case agreements. Maintain detailed provider enrollment files in electronic format, including electronically received documents and scanning of hardcopy documents, and document each stage of enrollment/reenrollment process thoroughly. Timely and accurately maintain all internal and external systems with appropriate provider information. Systems including, but not limited to, Qlikview, Epic, Echo, PET, CAQH and IGUIDE. Develop and maintain good working relationships with Nemours providers and support staff to obtain necessary and timely information to facilitate the provider enrollment/reenrollment process. Cultivate and maintain relationships with state representatives to facilitate the provider enrollment/reenrollment processes. Performs follow up with each out of state Medicaid plan to expedite participation approval. Respond and resolve problems with out of state Medicaid plans as it relates to denial of services or reimbursement related to enrollment by communicating with all levels of administrative and clinical personnel, managed care, central billing office and state representatives. Responsible for obtaining wet signatures, notarizing documents, and mailing paper application to state Medicaid plans to complete enrollment process for providers. Educate providers, administrators, and support staff regarding the enrollment/reenrollment processes and how it relates to the provider's ability to provide care to out of state Medicaid members. Work collaboratively with fellow team members to create, evaluate, and maintain department workflows, processes, policies, and systems. Responsible for monitoring the single case agreement report and out of state Medicaid work queue to ensure all providers within our policies are being enrolled and re-enrolled timely.
Requirements

HS Diploma or equivalent. Associate's degree preferred

Minimum of 6 months performing job-related duties in a healthcare environment.

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