Provider Enrollment Specialist
3 months ago
Full-time
Description
Shift: Monday - Friday, 8a-5p
Job Summary: Under the direction of the Clinic Manager, the Provider Enrollment Specialist is responsible for ensuring that all providers are enrolled with health insurance carriers in a timely manner. Responsibilities include preparation of health insurance carrier enrollment applications, follow-up with providers to ensure forms completion, verification of practice credentials, and verification of application status with insurance carriers, review of internal edits to ensure appropriate follow-up for provider enrollment related issues, communication with internal/external customers relating to the enrollment status. The position works in collaboration with other members of the KASH Alliance.
Job Duties and Responsibilities:
- Conduct reimbursement audit of enrollment to ensure that all providers are able to bill for services on a timely basis.
- Upon receive of notification from Administration, initiate the provider enrollment process. Enter all provider information obtained via the privileging/credentialing application into the privileged/credentialing system and generate all necessary payer application forms.
- According to each individual insurance carrier's requirements, determine and attach the application appropriate documentation, i.e, license, DEA registration, Board Certification and CV.
- Send completed applications to providers for signature and/or request additional information. Monitor outgoing/incoming applications, communication, as necessary, with billing office, clinic manager, and providers to ensure the timely return of requested information from providers.
- Maintain direct communication with Billing Supervisor to ensure the appropriate and timely enrollment of providers. Escalate issues that require additional attention before they become a major problem.
- Communicate with insurance carriers regarding receipt of applications, billing numbers or required attachments and the status of applications. Work claim edit and follow-up work queues to resolve enrollment-related issues.
- Answer phone calls and questions from representatives of various insurance companies, clinical departments, and billing office staff regarding enrollment information.
- Maintain organized reference files of enrollment information for follow-up correspondence with internal/external customers and to track the status of current applications.
- Maintain confidentiality regarding provider information.
- Perform other duties as assigned, including maintaining the ER physician shift schedule in coordination with the CEO, ER Director and physicians.
- Manage inbound and outbound calls relating to escalated claims issues, credentialing issues and or process.
- Assist other staff in the resolution of provider enrollment issues.
Requirements
Professional Requirements:
- Ability to be on-call on a regular basis to communicate with CEO, ER Director and physicians.
- Adheres to dress code; appearance is neat and clean.
- Completes annual educational requirements.
- Reports to work on time and as scheduled; completes work within designated time frame.
- Wears identification while on duty, uses computerized time system correctly.
- Completes organizational in-services as required.
- Utilizes access to internet web-based insurance resources for education, eligibility, follow up and billing as applicable.
- Maintains and ensures patient confidentiality at all times.
- Attends clinic meeting and or in-services.
- Works at maintaining a good rapport and a cooperative working relationship with physicians, departments and staff.
- Represents the organization in a positive and professional manner.
- Ensures compliance with policies and procedures regarding department operations, fire, safety and infection control.
- Complies with all organizational policies regarding ethical business practices.
- Communicates the mission, vision and core values of the organization.
- Demonstrates knowledge and/or location of Safety/Emergency Preparedness Manual, location of disaster packets, personal protective equipment and responsibilities during all Codes.
- Adherence with compliance of William Newton Hospital's and/or Physician Clinic policies. Demonstrates familiarity with employee handbook.
Regulatory Requirements:
- High school graduate or equivalent, Associate Degree preferred.
- Preferred 2 to 3 years of credentialing/provider enrollment experience.
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