Provider Enrollment Specialist

About the role

This position functions in a complex payer credentialing environment with changing health care rules, regulations and laws under the leadership of the Director of Professional Services. Responsible for the timely, efficient and accurate economic credentialing and provider enrollment of eligible West Virginia United Health System, WVU Health Sciences Eastern Division and WVU Health Sciences Charleston Division medical billing providers and facilities with contracted managed care and governmental plans. This position has continuous contact with internal and external customers including physicians, other healthcare providers, administrators, support staff and payor representatives. Additionally, this position is responsible for communicating provider participation information to stated internal and external customers through established processes to allow for appropriate patient scheduling and reimbursement for services rendered. Ensures compliance with regulatory agencies and maintains a working knowledge of statutes and laws that affect the credentialing/enrollment process. This position works collaboratively and gives support to the credentialing process.

Responsibilities

• In collaboration with hiring/onboarding personnel, serve as a concierge to guide providers through the economic credentialing/enrollment and recredentialing/revalidation process (managed care/Medicare/Medicaid/NPPES/I&A).
• Based on information from the provider enrollment vendor, develop, maintain and monitor a credentialing/enrollment database with applicable effective dates, to ensure active status among contracted managed care payers, Medicare, Medicaid and other governmental plans.
• Ensure licenses and certifications are accurate and active among all markets.
• Track and monitor the return of registration packets and alert hiring managers and/or recruiters of issues.
• Develop, manage, and utilize a standard set of reports to track the registration process and communicate status and successful enrollment to appropriate Vice Presidents, Administrators, Directors and Managers and billing units in an effort to manage the start date and prevent loss of revenue when possible.
• Regularly coordinate with IHS Vice Presidents, Administrators, Directors and Managers to obtain information for new facilities, practice locations, providers and services to be added under existing contracts for smooth revenue collection and contract compliance. This may require queries to the payers for strategic planning in advance of new services.
• Act as an educational resource related to enrollment of facilities, practice locations and various provider types and be available for consultation to internal and external clients.
• Analyze problems and draw accurate conclusions in regard to provider enrollment and credentialing issues.
• Proactively identify and troubleshoot issues affecting provider payment; resolve, provide recommended solutions, or forward more complex issues onto appropriate person(s) for handling.
• Work collaboratively with the Director of Professional Services, Manager of Professional Services, and Supervisor of Managed Care in regards to day-to-day operations and special projects.
• Maintain a high level of confidentiality in all aspects of the position.
• Have a basic understanding of messenger model network and managed care contracting as related to the credentialing process.
• Have a basic knowledge of credentialing policies, regulatory requirements and accreditation standards.

Requirements

• High School Diploma or equivalent.
• Two (2) years of health care industry experience.

Qualifications

• Health care industry experience in professional billing, physician's office, or credentialing preferred.
• Strong analytical, problem-solving, time management, planning and organizational skills with excellent attention to detail and accuracy.
• Ability to function independently with minimal supervision in a demanding and fast paced environment.
• Intermediate skill level in Microsoft Word, Excel, Access, and Outlook.
• Ability to establish and maintain effective working relationships with providers, staff, and other agencies; provide a positive service attitude when dealing with internal and external customers.

Working environment

The work environment characteristics described here are representative of those an employee encounters while performing the essential functions of this job. Standard office environment. Reasonable accommodations may be made to enable individuals with disabilities to perform the essential functions.

Schedule

Scheduled Weekly Hours: 40. Non-Exempt. Standard shift, United States of America.