Provider Enrollment Specialist

Responsibilities

• Timely and effectively enrolling practitioners in health plans.
• Maintain provider enrollment goals for all divisions.
• Validates up-to-date plan enrollment forms, completes applications, submits them to plans and follows up until enrollment is complete.
• Verifies accuracy and coordinates entry of new and revised provider information into IntelliCred and Master Database.
• Maps forms in IntelliCred and prioritizes work, reviewing and researching Health Plan Enrollment requirements at Corporate Business Office.
• Documents assignments in the Credentialing/Provider Enrollment tracking system per the department’s standard operating procedures.
• Contacts health plans to determine enrollment requirements periodically and verify health plan requirements based on the specialty and confirm the most up to date enrollment application forms are readily available in Provider Enrollment Tracking Software (IntelliCred).
• Prepares/reviews group applications based on information provided during acquisitions, Tax ID mergers, and Organic Growth Initiatives (OGI).
• Communicates with Business Development, Business Integration and Credentialing to acquire prospective new provider group’s required documents and/or signatures as needed.
• Knows how to use reporting system functionality, mapping forms utilizing Provider Enrollment tracking software and IC system Q/A delegate.
• Maintains provider’s profile in PE Tracking system (IC) with up to date with information on active or pending providers by completing all data fields in the Demographics, Appointments and Applications screen for the provider and group practice.
• Maintains provider’s profile in CAQH with up to date with information on active or pending providers by completing all data fields pertaining to demographics, service locations, group entity information, required documents and expirables.
• Maintains oversight to ensure enrollments currently assigned are being processed timely. i.e.: To Do List in IC, IntelliReports, IC Weekly aging, and IC End of Month.
• Validates status of on boarding provider’s enrollments to ensure Target Start Date is met. Escalates to Provider Enrollment management when necessary in order to meet desired Target Start Date.
• Performs other job-related duties within the job scope as requested by Provider Enrollment Management.

Qualifications

• Associate's degree (A. A.) or equivalent from two-year college or technical school.
• Three (3) or more years related experience or equivalent combination of education and experience.
• Knowledgeable with Group Entity health plan enrollments, state regulations and appeal processes.
• Knowledgeable in Provider Enrollment policies and procedures and ensuring they are being followed and keeping the loss of revenue from delayed enrollments at a minimum.
• Ability to read, analyze, and interpret common and technical journals, financial reports, and legal documents.
• Ability to respond to common inquiries or complaints from customers, regulatory agencies, or members of the business community.
• Ability to write speeches and articles for publication that conforms to prescribed style and format.
• Ability to effectively present information to top management, public groups, and/or boards of directors.
• Ability to work with mathematical concepts such as probability and statistical inference, and fundamentals of plane and solid geometry and trigonometry.
• Ability to apply concepts such as fractions, percentages, ratios, and proportions to practical situations.
• Ability to define problems, collect data, establish facts, and draw valid conclusions.
• Ability to interpret an extensive variety of technical instructions in mathematical or diagram form and deal with several abstract and concrete variables.
• Ability to understand medical terminology and protocols.
• Software Experience in Excel, Word, Adobe Professional, Pediatrix Master Database, OnBase, WorkView, hCue (Entity database software), CAQH, and Credentialing/Provider Enrollment Tracking Software (IntelliCred).