JOB SUMMARY:

The Enrollment Specialist is responsible for coordinating, monitoring, and maintaining the credentialing and re-credentialing process. While working under general supervision, the Enrollment Specialist administers the credentialing process for medical providers on behalf of a specified practice plan, or third-party insurance payer organization and hospital facility, ensuring that all credentialing, privileging and accreditation processes and procedures are completed in accordance with established regulatory, policy requirements and timelines.

The Enrollment Specialist ensures interpretation and compliance with the appropriate accrediting and regulatory agencies, while developing and maintaining a working knowledge of the statues and laws relating to credentialing, as well as reinforces and adheres to the core values of the company in order to achieve the mission and vision.

Essential Duties & Responsibilities:

§ Initiates, coordinates and monitors the acquisition and receipt of all credentialing documentation from new and existing providers; provides follow-up and problem resolution as required ensuring eligibility to hospital and third-party insurance carriers.

§ Coordinates the processing, distribution, and management of all credentialing, privileging and accreditation documents.

§ Identifies issues that require additional investigation and evaluation, validates discrepancies and ensures appropriate follow up.

§ Requests, coordinates and conducts background investigations and license verifications in support of all physician credentialing/accreditation applications.

§ Develops and implements systems and procedures to ensure that all credentialing, privileging and accreditation processes are completed in accordance with relevant regulation, policies, standards and timeframes.

§ Compiles and maintains current and accurate data for all payers/providers

§ Completes provider initial and re-credentialing applications, provider change forms and letters and successfully following up with Third Party insurance carriers as needed.

§ Accesses and navigates PECOS, Medicaid, NPPES, CAQH and additional sites/portals as needed.

§ Adheres to detailed instructions regarding the application procedures for enrollment and entering this information into the credentialing database and/or spreadsheets.

§ Acts as first point of contact for insurance carriers; frequent email and phone communication.

§ Assists in completing tasks and workflows to successfully track follow-up efforts and statuses of applications submitted.

§ Interfaces regularly with administration regarding credentialing related inquiries and operations issues.

§ Maintains and ensures strict confidentiality of files and databases, especially with regards to any disciplinary actions or malpractice suits.

§ Processes requests for clinical privileges, ensuring compliance with criteria outlined in clinical privilege descriptions.

§ Participates in assigned hospital committee’s and documents minutes.

§ Responds to inquiries from other healthcare organizations, interfaces with internal and external customers on day-to-day credentialing and privileging issues as they arise.

§ maintains a comprehensive credentialing/privileging database and prepares reports and summaries as appropriate and when requested; monitors the initial, reappointment and expiration process for physician profiles.

§ Completes payer/location applications.

§ Other additional administrative tasks, as assigned.

Summary of Qualifications:

§ High School Diploma or GED required; Associate’s Degree or Bachelor's / strongly preferred.

§ Prior Provider Enrollment experience strongly preferred.

§ Proficient use of Microsoft Office applications (Excel, in particular), internet resources and Adobe Acrobat.

§ Successful experience demonstrating the use of interpersonal skills necessary to communicate and gather info from all levels of personnel.

§ Quick learner; proven ability to research and problem solve effectively.

§ Proven ability to organize, prioritize and complete work, in a fast-paced environment, according to pre-established guidelines.

§ Must be reliable and possess extreme attention to detail and documentation.

§ Strong customer service orientation.

§ Must be able to work independently and as a contributive member of the Credentialing Team.