Provider Enrollment Specialist

4 weeks ago

Canton, United States Point32Health Full time

Job Summary

This role is responsible for providing enrollment support for the Tufts Health Plan, a Point32Health company. Under direction of the Provider Enrollment Supervisor, the Provider Enrollment Specialist processes, maintains, and revises all components of the provider information database for all THP products/plans. The candidate is responsible for the integrity of all practitioner information housed in THP provider data systems (i.e. TAHPMASTER, DIAMOND and CACTUS) and communicates with both internal and external customers by telephone, email and facsimile and in writing regarding practitioner information. The Specialist has comprehensive knowledge of IPA (Independent Practitioners Affiliations) specifics and is in contact with their counterpart regarding individual providers as well as changes within the IPA organization, working closely with the Contract Administrator to keep our Provider Network current. The Specialist also has knowledge regarding contracts and tax id forms, and many other supporting documents, as well as claims payment and claims forms and is a resource externally for providers and internally for numerous departments such as claims, member services, provider services, network contracting, and others.

The department is the business owner of THP’s provider network data systems and the candidate must be knowledgeable and familiar with the data content to ensure accurate entry. Data integrity is critical to ensure efficient claims processing, creation of accurate provider directories and mailings, and reliability of customer servicing information. Must have the ability to resolve complex issues independently and bring issues to a satisfactory resolution.

The Provider Enrollment Specialist provides Customer Service to IPA Contacts, Doctors, and other Providers, Billing Services and, internally, provides Customer Service and direction to Claims Operations, Provider Relations, Allied Health Services, Credentialing and Contracting.

 

Key Responsibilities/Duties – what you will be doing

DUTIES/RESPONSIBILITIES – what you will be doing (top five):

Assessment, validate and collect appropriate contract and supporting documents prior to adding or modifying provider data. Responsible for the execution of consistent, quality data input of provider information through discussion and discovery with providers and their contacts prior entering data into THP’s complex data systems (TAHP, DIAMOND, CACTUS). Elements requiring documentation for additions and modifications include, but are not limited to:

  • Demographic information
  • Provider payment information including group affiliations
  • New or additional IPA affiliations
  • New or additional hospital affiliations
  • Provider panel restrictions/closures
  • Provider coverage arrangements
  • Provider Terminations
  • Provider Category Changes
  • Product participation changes

Enter data of the elements as indicated above. Maintain various reporting tools and quality metrics for tracking provider information changes, including, but not limited to the Practitioner Change Reports for Commercial and Medicare Preferred.

 

Communicate and confirm provider information changes to individual provider and designated internal departments (e.g., Provider Service, Enrollment, Claims, NCPM)

  • Works with providers, directly and through other internal departments, to resolve conflicts over provider status and other issues.
  • Evaluate and assess correspondence directly from providers and/or internal departments regarding provider status or changes and maintain three databases as necessary.
  • Responsible for resolving tax identification issues for providers identified by the Internal Revenue Service.
  • Verify data is correct and complete in provider files for newly credentialed practitioners, and other providers including ancillary providers and/or ancillary facilities.

Ensure the adequacy and reliability of all information necessary for Provider Unit, Medical Groups, and Plan membership. On a daily basis, resolve and document issues requested via MACESS/IMAX in a timely manner, consistent with established dept standards. In coordination with the Provider Enrollment Supervisor, initiate, coordinate, and execute special projects relating to enhancements for system changes and provider information to improve the quality of provider data as it relates to plan operations.

 

Qualifications – what you need to perform the job

QUALIFICATIONS – what you need to perform the job

 

EDUCATION, CERTIFICATION AND LICENSURE:

B.A./B.S. or equivalent in health care or related field preferred.


EXPERIENCE (minimum years required):

Academic concentration in health care field or 1-2 years experience in health care field. Experience with personal computer required. Experience in database management systems preferred. Knowledge of Windows, Microsoft Word, Excel preferred.

 

SKILL REQUIREMENTS:

Must have the ability to maintain and manipulate a complex provider database. Must be able to prioritize multiple tasks and achieve deadlines. Must have ability to adapt to a changing environment. The position requires the ability to analyze and understand complex payment issues and plan operational concerns. Strong written and verbal skills are necessary. Individual must possess initiative, judgment, exceptional organizational skills as well as a keen attention to detail. Must be able to work cooperatively as a team member. Frequent contact, both written and verbal, with practitioners, office staff, billing agents and internal customers. Must use discretion when dealing with Plan providers and all other departments.

 

Commitment to Diversity, Equity & Inclusion

Point32Health is committed to making diversity, equity, and inclusion part of everything we do—from product design to the workforce driving that innovation. Our DEI strategy is deeply connected to our core values and will evolve as the changing nature of work shifts. Programming, events, and an inclusion infrastructure play a role in how we spread cultural awareness, train people leaders on engaging with their teams and provide parameters on how to recruit and retain talented and dynamic talent. We welcome all applicants and qualified individuals, who will receive consideration for employment without regard to race, color, religion, gender, gender identity or expression, sexual orientation, national origin, genetics, disability, age, or veteran status.

Who We Are

Point32Health is a leading health and wellbeing organization, delivering an ever-better personalized health care experience to everyone in our communities. At Point32Health, we are building on the quality, nonprofit heritage of our founding organizations, Tufts Health Plan and Harvard Pilgrim Health Care, where we leverage our experience and expertise to help people find their version of healthier living through a broad range of health plans and tools that make navigating health and wellbeing easier.

We enjoy the important work we do every day in service to our members, partners, colleagues and communities.

This job has been posted by Ignyte AI on behalf of Point32Health. Ignyte AI is committed to the fundamental principle of equal opportunity and equal treatment for every prospective and current employee. It is the policy of Ignyte AI not to discriminate based on race, color, national or ethnic origin, ancestry, age, religion, creed, disability, sex and gender, sexual orientation, gender identity and/or expression, military or veteran status, or any other characteristic protected under applicable federal, state or local law.

Req ID: R8083

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