Payor Enrollment Specialist

Essential Job Function

• Enrolls system-wide health physician and non-physician practitioners (CRNA, physician assistant, nurse practitioner, LCSW, etc.) in government (Medicare/Medicaid) and managed care plans.
• Maintains and updates the credentialing system with effective dates of participation, re-enrollment deadlines and requirements, provider numbers, and credentials to reflect the most accurate provider and location information.
• Maintains current knowledge of licensure and certification requirements in order to complete provider credentialing and re-credentialing applications.
• Helps review and interpret federal and state law that govern Medicare Accountable Care Organizations and/or Medicare Advantage plans to ensure regulatory requirements are adequately documented and tracked for compliance.
• Tracks and documents copies of all required credentialing documentation for all providers to ensure timely renewals.
• Tracks and maintains copies of current state licenses, DEA certificates, malpractice coverage and any other required credentialing documents for all providers and ensures timely renewals.
• Maintains knowledge of current health plan and agency requirements for credentialing providers.
• Complies with Medicare and Medicaid provider enrollment guidelines.
• Ensures accurate entry of data into CMS database for all CMS providers and suppliers.
• Requires understanding of CMS processes and requirements for rendering providers and service locations.
• Conducts follow-ups on credentialing, re-credentialing, revalidation, re-verification requests and demographic updates as received.
• Identifies issues requiring additional investigation and evaluation.
• Validates discrepancies and ensures appropriate follow up.
• Promotes appropriate escalation of enrollment issues toward timely resolutions.
• Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day enrollment issues as they arise.

Qualifications

• Education Required: High school diploma or equivalent.
• Preferred: Associate's Degree.
• Experience Required: 2 years' experience in administrative support functions in a physician practice.
• Proficient with Microsoft Excel.
• Preferred: 2 years working experience with insurance, managed care, or medical staff credentialing.