Provider Enrollment Specialist

The Provider Enrollment Specialist is required to work independently with minimal supervision, and is responsible for the accurate and up-to-date enrollment of all health care providers, midlevels, and ancillary providers for Billings Clinic with each of the required third party and/or government insurance payers. Responsibilities include the timely initiation of applications ensuring compliance with all government and payer regulations, timely follow-up of the applications pending, monitoring provider listings with vendors/payers to ensure proper in-network provider listings, and auditing payments/reimbursements to resolve denials. Works closely with the Physician Recruiter, the Medical Staff Office, Human Resources, Payer Relations, Patient Financial Services, Billings Clinic providers and leadership; as well as external payers and regulatory agencies.

Essential Job Functions

• Supports and models behaviors consistent with Billings Clinic’s mission, vision, values, code of business conduct and service expectations. Meets all mandatory organizational and departmental requirements. Maintains competency in all organizational, departmental and outside agency standards as it relates to the environment, employee, patient safety or job performance.
• Responsible for enrollment of all Billings Clinic Physicians, midlevels (Physician Assistants and Nurse Practitioners), ancillary providers (i.e., Dietitians, Physical Therapists, Speech Therapists, etc.) and facilities in government insurances such as Medicare, Medicaid, Medicaid Passport and DME for all states where Billings Clinic providers perform services and for all services in all programs which require provider enrollment. Tasks include new provider additions, revisions and terminations, and documentation of all enrollment activities. Ensures reenrollment is accomplished without deactivation/disruption to revenue cycle. Institutes appropriate follow-up and escalation as necessary.
• Responsible for enrollment of all Billings Clinic Physicians, midlevels (Physician Assistants and Nurse Practitioners), ancillary providers (i.e., Dietitians, Physical Therapists, Speech Therapists, etc.) and facilities with all commercial contracted insurance companies. Tasks include new provider additions, revisions and terminations, and documentation of all enrollment activities. Ensures reenrollment is accomplished without deactivation/disruption to revenue cycle. Institutes appropriate follow-up and escalation as necessary.
• Develops and maintains database of all individual provider demographic information for use in enrollment process. Develops and maintains database of all facility demographic information for use in enrollment process. Provides pertinent data to internal and external contacts when appropriate and as needed for audits or other projects.
• Develops and maintains database with contracted insurance company requirements for enrollment, re-enrollment, method of communication, contact information, confirmation, or other criteria, including rules for updates.
• Responsible for audits of insurance carriers’ provider directories annually, or more frequently as needed, to ensure accurate and up-to-date listings are maintained. Coordinates updates with insurance carriers as needed. Develops audit criteria/guidelines on what and when audits will occur. Audits may include provider demographics, specialties in which they are enrolled, and/or plans/contracts in which they are enrolled. Coordinates audits with various vendors annually prior to printing their listing of participating providers to ensure highest level of accuracy and marketing impact to attract new patients.
• Responsible for maintenance of National Provider Identification (NPI) numbers for all Billings Clinic providers and locations requiring separate identification. Proactively obtains up-to-date regulatory requirements. Institutes appropriate follow-up and escalation as necessary. Determines appropriateness of incoming requests for this information and coordinates information with other organizations/providers that may need this information.
• Acts as the liaison between Billings Clinic and vendors who assist with enrollment of Billings Clinic physicians, midlevels and facilities in programs, including out-of-state Medicaid. Responsible for maintaining collaborative relationship, as well as ensuring timely receipt of enrollment notification to avoid timely filing write-offs for care rendered. Institutes appropriate follow-up and escalation as necessary.
• Responsible for ensuring the timely receipt of necessary information from physicians, midlevels and ancillary staff in regard to enrollment needs to assure billing and reimbursement capability in a timely fashion. This includes working directly and independently with clinical operations management, medical staff services, human resources, physician recruitment staff, reserve/temporary staffing department, and physicians, midlevels and ancillary personnel.
• Responds to inquiries from patients, Billings Clinic staff, and outside referring providers as to Billings Clinic provider participation in specific insurance carrier plans.
• Acts as resource to Coding Resources and Patient Financial Services for regulatory compliance with billing and enrollment inquiries.
• Researches and resolves payment denials for enrollment issues in response to patient, payer provider representative, and/or Patient Financial Services inquiries.
• Coordinates and ensures accuracy and timely information from insurance carriers to appropriate personnel within Billings Clinic for entry into the physician masters for billing purposes.
• Serves as subject matter expert for Billings Clinic Payer Relations regarding enrollment requirements. Researches national, regional and local market enrollment trends and requirements. Responsible for learning and applying contract terms. Ensures accurate enrollment, as each market location (i.e., Bozeman, Miles City, Cody) may need different plan contacts and have different vendors.
• Creates reports in support of enrollment audit function, or Payer Relations research for special projects.
• Identifies and implements process improvements in all aspects of the provider enrollment process. Participates in and/or leads and facilitates teams and committees as appropriate.
• Identifies needs and sets goals for own growth and development; meets all mandatory organizational and departmental requirements.
• Performs other duties as assigned or needed to meet the needs of the department/organization.