PROVIDER ENROLLMENT SPECIALIST

1 month ago

Caribou, United States Cary Medical Center Full time

Job Type

Full-time

Description

Job Summary:

The Provider Enrollment Coordinator (PE) will be responsible for the entire oversight of the provider enrollment process which involves, but not limited to, enrolling new and established employed and contracted providers with all types of health plans; and maintaining the initial enrollment, revalidation, and termination of health plan provider participation. The PE Coordinator is also responsible for preparing and submitting credentialing/enrollment applications and supporting documentation for enrolling individual physician's groups with payers. The PE Coordinator follows up on the status of applications for all practitioners and payers, tracking progression on all pending and completed applications.

Essential Duties:

  1. Responsible for provider enrollment with Medicare, Mainecare, Anthem and other contracted payors.
  2. Responsible for submission of Mainecare maintenance cases.
  3. Responsible for oversight of Medicare facility and practice revalidations for the Hospital and Pines locations, respectively.
  4. Facilitates, completes, maintains the enrollment application process for all employed and contracted healthcare providers (medical doctors and advance practice providers) with the various commercial, managed care, and governmental payors.
  5. Preparing and submitting credentialing applications for providers and must maintain timelines on enrollment/credentialing schedules and provide leadership with status updates. Communicate with other department's updates as needed.
  6. Clarify carrier information requirements and maintain a strict level of confidentiality for all matters pertaining to provider credentials.
  7. Work closely with Medical Staff Services to obtain missing documentation for providers pertaining to provider enrollment. Obtain required signatures and follow-up on status of application process and documentation submitted.
  8. Maintain provider information including demographics for all providers for both organizations.
  9. Maintain provider credentialing files electronically, shared computer files, and CAQH (Council for Affordable Quality Healthcare).
  10. Monitor and plan for updates related to licensure expirations and renewals.
  11. Follow up on all pending applications with payers at least every 30 days.
  12. Resolve issues related to provider participation.
  13. Verify provider loads are completed correctly with all lines of business.
  14. Conduct training as needed in regard to payer enrollment.
  15. Works with payers to facilitate issue resolution, re-enrollment, and termination requirements.
  16. Coordinates responses to inquiries regarding payer's and enrollment inquiries; follows up with each payer and or provider to completion; assesses provider credentialing files to determine if additional information is required; revisits state and federal bulletins for provider sanctions.
  17. Corresponds with providers, staff, and network provider relations staff to coordinate/confirm network provider participation; communicates to internal and external parties' provider enrollment information and status.
  18. Completes dis-enrollments, notifies health plans of termination/resignations.
  19. Clarify carrier information requirements, and maintain a strict level of confidentiality for all matters pertaining to provider credentials
  20. Responsible for the oversight of the charge entry process which includes but not limited to, following up on charge corrections and accurate charge entry information.
  21. Completes other duties as assigned.
Other Duties:

1. Complies with local, state and federal laws and regulations.

Requirements

License and Education:
  1. To perform this job successfully, an individual must be able to perform each essential duty satisfactorily. The requirements listed below are representative of the knowledge, skill, and/or abilities.
  2. Knowledge of provider enrollment processes and requirements for commercial, state, and community insurance companies. CMS Federal and State Guidelines related to enrollment policies
  3. Ability to interact with tact and diplomacy with individuals from a variety of backgrounds and organizational levels
  4. Ability to effectively communicate both in writing and verbally, as well as interact in a professional manner with colleagues (i.e. claim coordinators, account managers, and provider services), health centers staffing and the public
  5. Ability to work independently and make sound and timely decisions is a must
  6. Communicate effectively with all departments, client staff, and insurance contacts
  7. Demonstrated PC skill (i.e. proficient in Microsoft Office products including word and excel, project management, power point and outlook)
  8. Familiar with the Internet, able to do in-depth searches
  9. Ability to multi-task, excellent organizational skills and planning skills required
  10. Strong analytical and problem-solving skills
  11. NAMSS certification; preferred not required (CPCS or CPMSM).
  12. Extend work hours; if required depending on deadlines and events

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